Health Care Financing Flashcards Preview

Health Care Systems > Health Care Financing > Flashcards

Flashcards in Health Care Financing Deck (28)
Loading flashcards...
1

Why was WWII a spring board for insurance?

Wage freeze
Created incentive to increase fringe benefits in order to bargain with unions
Medical insurance quickly became a primary benefit that the employer paid for

2

Pre WW2 insurance?

9% of population

3

After WW2 (by 1952) insurance?

>50% of the population had insurance

4

Why is insurance needed?

Mitigate (reduce) the financial risk of the insured (lost income)
Pay premiums now so if large sum is needed later the insurer pays most of it, thereby protecting the insured’s income
Premiums paid by the many reduce the financial risk of the few who need it

5

Way to pay for insurance:

private
public

6

Who is paying for private insurance?

Employers who pay for 75+% of premiums
Individual where insured pays 100% of premiums

7

Who is paying for public insurance?

government sponsored insurance
Taxes pay for all or most of the premiums

8

What happens to prices when third parties are involved?

increase

9

Moral hazard and provider behavior:

Moral hazard will also drive decisions health care leaders make
More of that which pays better
Less of that which pays less

10

When did APTA secure coverage for PT services?

under Medicare as the bill was being worked in Congress in 1964

11

Secondary effect of PT being covered under Medicare?

effect of PT being included in most insurance benefit plans

12

What determines who has access to health care services?

insurance or lack thereof

13

What is a moral hazard?

Demand for a product/service goes up when it is paid for by another

14

Community Rating

everyone in that insurance plan pays the same premium

15

Experience Rating

businesses pay different premium amounts based on the health (or healthcare utilization) of their employees

16

In which rating does the employer pay less in premiums in they have healthy people?

experience rating

17

Health Care Expenditures =

Payment X Quantity/Utilization

18

Payers can influence health care expenditures by manipulating:

Amount actually paid (not what providers charge) = Allowable
Utilization

19

Is rationing implicit or explicit?

implicit

20

How is rationing implicit?

by manipulating PRICE (payment)
utilization
knowledge

21

Utilization

PCP gatekeeper
Insurer utilization review and determination of “medically necessary” services: subjective and arbitrary

22

Knowledge

Hidden insurance restrictions
One page summary when signing up, then 50+ page manual with details about what is covered and what is not covered

23

What is a favorite method to pay less for a given service?

discounted fee-for-service (DFFS)

24

How to reduce cost?

1. Less equipment
2. Fewer supplies
3. Reduce public relations and marketing activities
4. Outsourcing
5. Type (cost) of staff
a. Professional versus mid-level versus technician/aide
6. Quantity of staff
a. Productivity = ratio of output (e.g., units billed) to input (hours paid)
7. Change goals
a. Move to next level of care as soon as possible instead of aiming for complete independence in current setting
8. Flattened administrative/management structures

25

How is cost transferred to the patients?

deductible
copay
coinsurance

26

Deductible

amount insured must pay up front before insurance pays for anything

27

Copay

predetermined amount payable to the provider that is due at the time service is rendered

28

Coinsurance

percentage paid by the patient after the service is complete and the insurer determines, via the Explanation of Benefits (EOB), what the patient owes toward the allowable