Chapter 1 Delivering Healthcare part 2 Flashcards
How do the uninsured have universal coverage in the US?
Hospital EDs are required to evaluate a pt’s condition and render medically needed services for which the hospital does not receive any direct payments unless the pt is able to pay
Definition of primary care
Basic and routine healthcare provided in an office or clinic by a provider who takes responsibility for coordinating all aspects of a pt’s healthcare needs; an approach to healthcare delivery that is the pt’s first contact with the healthcare delivery system and the first element of a continuing healthcare process
Define universal access
The ability of all citizens to obtain healthcare when needed
What type of market is the US healthcare system?
A quasi-market or an imperfect market
Why is the US healthcare system a quasi-market?
The health plans, not the pts, are the real buyers in the healthcare services market
Prices are determined by payers
In certain geographic sectors of the country, a single giant medical system has taken over as the sole provider of major healthcare services, restricting competition.
Knowledge about new diagnostic methods, intervention techniques, and more effective drugs is part of the domain of the physician, not the pt
Health insurance has the effect of insulating pts from the full cost of healthcare.
The current system has drawbacks that obstruct information-seeking efforts on pricing (i.e., item-based pricing)
Characteristics of a free market
Pts and providers act independently, with pts able to choose services from any provider.
Providers do not collude to fix prices, and prices are not fixed by an external agency.
Demand is driven by the prices prevailing in the free market.
The quantity demanded will increase as the price for a given product or service declines.
Definition of demand
The quantity of healthcare purchased
Definition of moral hazard
Consumer behavior that leads to a higher utilization of healthcare services because ppl are covered by insurance
What are two factors that limit pts’ ability to make decisions in the healthcare system?
Decisions about the utilization of healthcare are often determined by need rather than by price-based demand
The delivery of health care can itself create demand
Definition of need
The amt of medical care that medical experts believe a person should have to remain or become healthy
Definition of provider-induced demand
Artificial creation of demand by providers that enables them to deliver unneeded services to boost their incomes
Definition of phantom providers
Practitioners who generally function in an adjunct capacity; the pt does not receive direct services from them. They bill for their services separately, and the pts often wonder why they have been billed.
Definition of package pricing
Bundling of fees for an entire package of related services
Definition of single-payer system
A national healthcare program in which the financing and insurance functions are taken over by the federal government
How do multiple payers make the system more cumbersome?
It is extremely difficult for providers to keep tabs on numerous health plans.
Providers must hire claims processors to bill for services and monitor receipt of payments. Billing practices are not standardized, and each payer establishes its own format.
Payments can be denied for not precisely following the requirements set by each payer.
Denied claims necessitate rebilling.
When only partial payment is received, some health plans allow the provider to balance bill the pt for the amt the health plan did not pay. Even when the balance billing option is available to the provider, it triggers a new cycle of billings and collection efforts.
Providers must sometimes engage in lengthy collection efforts
Gov’t programs have complex regulations for determining whether payment is made for services actually delivered.
