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From Flashcardlet > Issues Final > Flashcards

Issues Final Flashcards

1
Q

What is meant by healthcare financing in its broad sense?

A
  • Enables people obtain health insurance

- Determines reimbursement and undertakes actual payment for services received by the insured

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2
Q

What impact does financing have on the healthcare delivery system?

A
  • Determining access to health care services

- Influences how much health care is produced

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3
Q

What are the four fundamental principles for insurance?

A
  • Risk is unpredictable for the insured
  • Risk can be predicted with a reasonable degree of accuracy for a group or population
  • Transfers risk from individual to the group through the pooling of resources
  • Actual losses are shared on some equitable basis by the insured
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4
Q

What are the 6 types of private insurances available?

A
  • Group Insurance
  • Self-insurance
  • Individually purchased
  • Managed care plans (HMOs PPOs)
  • High-deductible health plans
  • Medigap
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5
Q

What are the differences between the 6 private insurances?

A
  • Group Insurance (Employer; risk spread through entire group)
  • Self-insurance (Employer; has more control of insurance costs; exempt from some gov’t regulations)
  • Individually purchased (Self-employed; determines premium price and eligibility based on risk by individuals health status and demographics)
  • HMOs/PPOs (Assume responsibility for finance, insurance, payment, and delivery)
  • High-deductible health plans (high deductable, low premium; Consumers have more control of funds; HRA = Employer, HSA = individual)
  • Medigap (Only available to Medicare beneficiaries to cover expenses not covered by Medicare)
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6
Q

What is a Premium?

A
  • Amount charged to insure against specified risks

- Determined by actual risk

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7
Q

What are Covered Services?

A

Services that are included in the contract that you pay a premium for.

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8
Q

How does cost sharing apply to health insurance?

A
  • Employers and employees generally share in the cost of premiums
  • Insured also pays out of pocket deductibles and copayments/coinsurance
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9
Q

What is Coinsurance?

A

Set proportion of medical costs insured must pay out of pocket.

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10
Q

What is Medicare Part A?

A
  • Hospital insurance of medicare
  • Financed by payroll taxes for Social Security
  • 1.45% is taxed from employee and employer
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11
Q

What is a Benefit Period?

A

When an individual begins hospitalization and ends when they have not been in the hospital for 60 days.

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12
Q

Which benefits are covered by Medicare Part A?

A
  • Hospital inpatient services
  • Care in a skilled nursing facility
  • Home health visits
  • Hospice Care
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13
Q

Which benefits are not covered by Medicare Part A?

A
  • Long-term care
  • Custodial services
  • Personal convenience (TV, Phone, etc.)
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14
Q

What is Medicare Part B?

A
  • Supplementary Medical Insurance (SMI) of Medicare

- Voluntary program financed by general tax revenues and required premium contributions from enrollees

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15
Q

What are the main services covered by Medicare Part B?

A
  • Outpatient services (Physician services)
  • Hospital outpatient services (outpatient surgery, diagnostic tests, etc.)
  • ER visits
  • Outpatient rehab services
  • Renal dialysis
  • Prostheses
  • Medical equipment and supplies
  • Annual exams with preventative services
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16
Q

What are the services not covered by Medicare Part B?

A
  • Dental care
  • Hearing aids
  • Eyeglasses (except for after cataract surgery)
  • Services not related to treatment or injury
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17
Q

What is the Medicare Advantage Program?

A
  • Program took effect in 1998
  • MMA changed name to MAP in 2003
  • Provides additional choices of health plans
  • Tries to get more beneficiaries into managed care plans
  • May have lower out of pocket costs than original Medicare program
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18
Q

Explain the prescription drug program under Medicare Part D.

A
  • Voluntary
  • Stand-alone Prescription Drug Plan (offers drug coverage to those who want to stay in original Medicare Program)
  • Medicare Advantage Prescription Drug Plans (Those who want to obtain all health care services from Part C)
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19
Q

What provisions has the federal government made for providing health care to military personnel and to veterans of the US armed forces?

A
  • Health care handled by DOD (Department of Defense)
  • Tricare is insurance for military health care
  • Active duty automatically in Tricare
  • VHA is funded by Congress and also operate CHAMPVA
20
Q

What are the major methods of reimbursement for outpatient services?

A
  • Fee-for-service reimbursement
  • Bundle services
  • Resource-based relative value scale
  • The preferred-provider
  • Capitation
  • Salary combined with productivity bonuses
  • Ambulatory Payment Classification
21
Q

Properties on retrospective methods of reimbursement.

A
  • Based on actual cost incurred in the past
  • Directly related to length of stay, services rendered, cost of providing services
  • Providers can raise costs and not be sensitive for efficiency and cost containment of delivery of care
  • Cost increases are essential for reimbursement and profit
22
Q

Properties on prospective methods of reimbursement.

A
  • Pre-established criteria are used to determine amount of reimbursement
  • Related to resource inputs
  • Providers have incentive to reduce cost and provide services more efficiently
  • Cost increases lead to loss absorbed by provider
23
Q

Discuss the prospective payment (PPS) system under DRGs (Diagnosis-Related Group).

A
  • PPS is used by Medicare for acute-care inpatient hospital reimbursement
  • Rates are adjusted for geographic wage differences, location of hospital, teaching hospitals, and hospitals that serve poor people
  • Cases are paid for that are outliers (long stays or very expensive bills)
24
Q

What do National Health Expenditures measure in a year within the U.S.?

A
  • Cost of health services and supplies
  • Health-related research and construction
  • Costs incurred in private and public health insurance
25
Q

What do Personal Health Expenditures measure?

A

Services and goods related directly to patient care.

26
Q

What is Adverse Selection?

A

When high risk individuals enroll into an insurance plan with healthy people as well.

27
Q

What are the consequences of adverse selection?

A

Premiums have to be raised for everyone, which makes insurance less affordable for those in good health.

28
Q

What is Risk Rating?

A

Adjusting premiums to reflect health status and making potential high-cost enrollees pay more.

29
Q

Why is Risk Rating criticized?

A

High-risk individuals may be unable to acquire insurance at affordable prices.

30
Q

Describe how some of the changes in the health services delivery system have led to a decline in hospital inpatient days and a growth in ambulatory services.

A
  • Medicare instituting PPS gives hospitals more of an incentive to shorten inpatient length of stay and continue care in an outpatient setting
  • Cost-saving efforts of managed care also lead to a decline
  • Outpatient sector has fewer payment restriction
31
Q

What implications has the decline in hospital occupancy rates had for hospital management?

A

Hospitals forced to view ambulatory care as essential inpatient care rather than supplemental.

32
Q

All primary care is ambulatory, but not all ambulatory services represent primary care. Why?

A
  • Primary care being delivered on an outpatient basis renders all primary care ambulatory
  • Secondary and Tertiary care is also considered to be ambulatory and that is not primary care
33
Q

What is the Gatekeeping role of primary care?

A

Primary care prevents patients from undergoing unnecessary procedures and treatment.

34
Q

What is Community-Oriented Primary Care (COPC)?

A

COPC takes the good elements of primary care and implements that into local communities to address issues on a population basis.

35
Q

Discuss the two main factors that determine what should be an adequate mix between generalists and specialists.

A
  • How rigidly a health delivery system employs the concept of gatekeeping
  • The propensity of people to utilize PCPs
36
Q

Why is it important for hospital administrators to regard outpatient care as a key component of their overall business strategy?

A

Because outpatient services is now a main source of profit for most hospitals due to the inpatient revenue steadily decreasing.

37
Q

Discuss the main hospital-based outpatient services.

A
  • Clinical
  • Surgical
  • Emergency
  • Home Health
  • Women’s Health
38
Q

Why is the hospital emergency department sometimes used for non-urgent conditions? What are the consequences?

A
  • Used due to individuals who are uninsured or are Medicaid beneficiaries have no pcp have to resort to ER due to them being obligated to see and evaluate every patient
  • This improper usage wastes precious resources
39
Q

What is the basic philosophy of home health care?

A

Maintain people in the least restrictive environment possible.

40
Q

Describe the services provided through home health care.

A
  • Nursing care
  • PT/OT
  • Speech therapy
  • Homemaker services
  • DME services
41
Q

Describe the types of care provided by hospices.

A
  • Medical (pain/nausea)
  • Psychological (anguish)
  • Counseling/Spiritual (accepting death)
42
Q

Describe the scope of public health ambulatory services in the United States.

A
  • Immunizations
  • Outpatient services
  • Well-baby care
  • Venereal disease
  • Family planning
  • Tuberculosis screening
  • Mental health
43
Q

What are some challenges the main public and voluntary outpatient clinics face?

A
  • Inadequately funded
  • Recruiting and retaining qualified physicians
  • Death of patients covered under private insurance or those can pay for services
44
Q

What are CHC’s?

A

Community health clinics offer services for little to no payment to the poor and homeless near affluent neighborhoods.

45
Q

What is Alternative Medicine?

A
  • Treatment that is considered non-conventional such as herbal formulas/acupuncture
  • Efficacy of treatments has not been scientifically established
46
Q

What role does alternative medicine play in the delivery of health care?

A
  • Tends to be the sought out treatment after an individual exhausts all westernized medicine due to alternative care providers being more understanding and taking time to listen
  • Looked down upon due to how unconventional it is viewed to be
47
Q

What are the 6 main factors of hospital growth in the U.S.?

A
  • Advances in medical science
  • Development of specialized medical technology
  • Advances in medical education transformed hospitals into institutions of medical practice
  • Development of professional nursing ensured increased efficacy of treatment, and hygiene basis
  • ## Insurances provide a vehicle for people to pay for hospital services

From Flashcardlet (104 decks)

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