3) Health Care Financing, Access, Payment, and Formats

Question 1

What are the types of payment for health care?

Answer 1

• Out-of-pocket
• Individual private insurance
• Employer-based private insurance
• Govt financing

Question 2

As of 2013, the highest percentage of the national health expenditure went towards what type of payment?

Answer 2

Government financing

Question 3

Out-of-pocket payment

Answer 3

2 party-deal involving cash or barter

• Was the most common payment type until the mid-20th century

Question 4

Individual Private Insurance

Answer 4

Third-party system where the insurer acts as the third party and is included in transactions btwn the two basic parties (pt/consumer & provider)

• Requires 2 transactions:
  
  • Consumer premiums to insurance company
  • Insurer reimburses the provider

Question 5

Employment-Based Private Insurance

Answer 5

Type of third-party payment system where the employer pays the premiums to the insurance company

Question 6

Describe the purpose of govt-financed health care

Answer 6

• Redistributes the funds from wealthy to the poor, elderly, and people who can access insurance through their job

Question 7

How does govt-financed health care work?

Answer 7

An individual enrolls and taxpayers subsidize and then the govt pays the provider

Question 8

Medicare Part A

Answer 8

Inpatient hospital insurance plan financed through social security

Question 9

Medicare Part B

Answer 9

For outpatient/physician services; Financed by federal taxes and monthly beneficiary premiums

• You have to pay into it

Question 10

Medicaid

Answer 10

State-run programs for low-income peeps; Funded by federal and state taxes

• Have to qualify for this

Question 11

Medicare Part D

Answer 11

Prescription drug coverage

• Optional

Question 12

CHIP

Answer 12

Companion program to Medicaid to make it easier for kids to get coverage

• Implemented in the 1990’s

Question 13

Describe the 3 types of health care financing

Answer 13

Progressive - Pay more as you make more based on tax brackets

Regressive- Pay a fixed percent; Not based on income

• Most common in US

Proportional- Proportional to income

Question 14

Access

Answer 14

The timely use of personal health services to achieve the best health outcomes; A person’s ability to obtain health care services when needed

Question 15

Availability

Answer 15

Can you get the (special) services you need?

Question 16

Accessibility

Answer 16

Payment options, Convenience, Physical access to the office

Question 17

Affordability

Answer 17

Individual’s ability to afford coverage and meet cost-sharing requirements

Question 18

Acceptability

Answer 18

Bedside manner; Cultural competance

Question 19

How does lack of insurance affect access to health care?

Answer 19

It delays the seeking of care, the condition worsens, and then more skilled/costly care is needed

Question 20

True or false: Uninsured kids can access care more easily than uninsured adults?

Answer 20

True

Question 21

Market Justice

Answer 21

Free market where health care is an economic good and based on people’s ability to pay

• Tends to be the school of thought for the politically conservative

Question 22

Social Justice

Answer 22

Runs under the belief that health care is a right so the government assists w/allocation

• Tends to be the belief for democrats

Question 23

Moral Hazard

Answer 23

People are more likely to seek care when someone else is paying for it

Question 24

Health Disparity

Answer 24

A higher burden of illness, injury, disability, or morality on one group relative to another

Question 25

Health Care Disparity

Answer 25

Differences btwn groups in health coverage, access to care, and quality of care

Question 26

What are the types of payment methodologies?

Answer 26

* Self-pay * Fee for service * Bundled * Per diem/per visit * Per episode * Capitation

Question 27

Self-Pay

Answer 27

Cash-based services where the pt directly pays the provider for services * Bill is given directly to the pt * Pt can submit to insurance * Maximizes cash flow and minimizes administrative burden on the provider * Limits market to those who are willing/able to pay

Question 28

Fee for Service

Answer 28

Provider reports each service delivered w/a fee for each * Basis of payment for outpatient PT * Uses CPT codes * Fees/charges are set by the provider * Leads to overutilization

Question 29

Per-Visit/Per Diem

Answer 29

Bundled payment where one lump sum payment is given for each visit regardless of a number of services provided * Moving more towards this trend * Can require CPT codes

Question 30

Per-Episode Payment

Answer 30

One lump-sum payment is given for an episode of care * Not based on charges→Quality measures are attached to this * Allows the provider freedom to select which services will be provided * Associated w/reduced administrative costs * Basis for diagnosis-related groups * Issues=Accuracy of dx/px, outliers, definition of "episode"

Question 31

Capit

Answer 31

A monthly/yearly lump-sum payment that covers all subscribers * Incentivizes to keep the population healthy * High risk to provider

Question 32

Describe risk pattern for self-pay

Answer 32

High risk to pt; Low risk for provider

Question 33

Describe the risk pattern for fee-for-service

Answer 33

High risk to payer

Question 34

Describe the risk pattern for bundled services

Answer 34

High risk for provider

Question 35

What payment methods are used for hospitals?

Answer 35

Fee-for-service and Per-diem

Question 36

Diagnostic Related Group

Answer 36

A type of per-diem payment under medicare part A where payment rates are based on the resources needed to care for each DRG

Question 37

What payment methods are used for inpatient rehab?

Answer 37

Per-diem, Private managed care, or prospective payment system (PPS)

Question 38

PPS

Answer 38

Utilizes info from the pt assessment instrument to classify pt's into groups and payment is linked to the pt's fxnl level

Question 39

What payment methods are used for SNF's?

Answer 39

Contract, Per-diem, or Medicare PPS * Part A rates based on case mix using a resident classification system

Question 40

What payment methods are used for long-term care hospitals?

Answer 40

PPS

Question 41

What payment methods are used for home health?

Answer 41

Medicare, Medicaid, Fee-for-service, Managed care, or Private Pay

Question 42

Describe Medicare Part A: Home Health

Answer 42

* PPS * Predetermined base payments are given to the agency based on case mix adjustments for pt's conditions and needs of pt * Rates are adjusted to geography * Based on the OASIS * Consolidated billing for nursing, therapy services, medical supplies, home health aides. & medical social services

Question 43

What is the basis of payment for Medicare Part B?

Answer 43

Physician Fee Schedules ## Footnote Medicare pays the provider 80% of the fee schedule amount and the pt is responsible for the remaining 20%