Health Care Delivery

Question 1

What are the three eras of US health care change?

Answer 1

pre industrial
post industrial
corporate era

Question 2

What are the 4 main features of the corporate era?

Answer 2

corporatization
growth of non-physician workforce
information revolution
globalization

Question 3

What is the strucutre of the ACA passed in 2010?

Question 4

What were common occurences prior to ACA?

Answer 4

denying–people with pre-exisitng conditions or in certain occupations
excluding – people with pre-existing condition
charging– higher premiums to people based on gender or health
limiting– limited benefits to people with pre existing conditions, mental health etc..
imposing– lifetime or annual benefit caps

Question 5

What is guaranteed issue?

Answer 5

concept that if an individual applies for healthcare policy then company must sell them a policy (everyone needs to be insured)

Question 6

What is the insurance mandate?

Answer 6

when government requires everyone to have insurance

Question 7

What is underwriting?

Answer 7

idea that individual applies for a policy and company looks at their risk factors (pre-exisint conditions and refuses to sell) can either not sell, increase rates (avoid the sick, choose the healthy)

Question 8

What is a risk pool?

Answer 8

how risky the group of people you are insuring are

adverse selection – normally increase the rates of premiums, large pool with more sick than healthy= MOST risk

favorable selection– large pool, with more health than sick

Question 9

What is community rating ?

Answer 9

idea that the US as a whole, that each individual will have the same premium regardless of preexisting conditions of individual factors– spreads the risk

Question 10

What is an individual rating?

Answer 10

based on age, gender, ethnicity, or health staus– exclusive prior to the ACA

Question 11

What is recision>

Answer 11

recission is when an insurer takes actions retroactively to cancel a policy holder’s coverage by citing omissions or errors in application– in order to revoke their policy

Question 12

What is modified community rating?

Answer 12

can charge different rates based on characterisitcs of the community rather than the individual– get more people into the pool

Question 13

What is a premium and how is it determined?

Answer 13

is your monthly payments – paid regardlness if using care or not

competition– holds prices in check

Question 14

Who are the players of healthcare?

Answer 14

providers
payers/insurance
patients
pharmacy (suppliers)

Question 15

What are the types of cost-sharing

Answer 15

co-pays= flat amount of $
co-insurance – dependent on policy
deductible

Question 16

What is power asymetry?

Answer 16

idea that people have certain reverebce for providers having more knowledge
provider is the superior knowledge therefor is the decision maker

Question 17

What is shared decision making?

Answer 17

idea that there is no large power differential
inherently assymes that patients are capable of taking in complex information from health care providers

Question 18

What is the moral hazard theory?

Answer 18

trend towards more risky behavior because the individual knows that he/she won’t have to cover the full cost
someone else will pay for my mistake, so more likely to take risk

Question 19

What are the types of managed healthcare?

Answer 19

HMO
PPO
Consumer directed health plans (HSA)

Question 20

What are the components of an HMO?

Answer 20

exclusive provider organization (EPO)– more restrictive
network size=small
must see a PCP before specialist
provider reimbursement= negotiated fee/ contracted rate w/ a co-pay
cheaper premiums than a PPO
cost sharing is lower out of pocket cost to member

Question 21

What are the components of a PPO?

Answer 21

have a larger network size than HMO
do not require PCP visit
provider reimbursement =negotiated fee/ contracted rate w/ typically co-insurance
less reestrictibe
more expensive premium
higher out of pocket cost

Question 22

What are the components of an HSA?

Answer 22

created by a provision in the Medicare prescription drug improvment and modernization act
typically very large network
full access to specialist
provider reimbursement= pt paying majority
premium is very low
cost sharing= very high deductible
max= $6650 for self

Question 23

What is fee for service?

Answer 23

CPT codes used for determining payment amount
encourages overutilization

Question 24

What is payment by episode/ prospective payment system?

Answer 24

pre-determined amount paid by insurance to provider
CPT used for charging but do not impact payment amount
Medicare like to pay of IP using payment by episode – diagnosis related groups (DRG) in acute care

Question 25

What is payment per diem?

Answer 25

flat amount paid to provider regardless of charges
exact amount is called the negotiated rate