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Usual and customary charge?

Providers decide how much they're worth and set their own prices


Blue Cross Global Budgeting Scheme?

Outcome-based payment. If you spend less money, and do a better job with quality stuff, then we'll pay you more and you get to keep the money you saved.


In the British movie, who had control?

Physicians - Act to control their work environment


What did you learn about institutional cultures from the British movie?

Institutional cultures form relatively early in the life of the institution and tend to have massive inertia and are resistant to change. New people come in and USUALLY get absorbed into that culture. Change is possible, not easy.


What was the British Policy change?

NHS changed from budgeting the hospital to having the money follow the patient. With patients able to go to other places, hospital is losing money because of ridiculous waiting times.



Increased deductibles/copayments/coinsurance - insurance company pays less, subscriber pays more


3 things that determine life expectancy?

Women > men, race plays a factor, education


3 reasons to have a doctoral degree?

1) More money for fees 2) More autonomy 3) Ensures high professional standard


Consequences for pushing towards a doctoral degree?

Greater access to primary care means higher total system costs!!


Which med organization lobbies the most?

AMA= lobbies more than other people. Lots of good causes, lots of bad causes (monopolizing the MD profession)



Full time equivalent - like, generally 40 hours per day


Problem with physician shortage?

While you have an increasing number of docs, FTE is actually not as much. Number of spots in med school and residencies is low, and we need to make up for difference in numbers. Also, there's an aging population.


Physician mismatches in the country?

People in south and west have fewer docs than necessary to treat the population


What's it called when private payers pay more for private insurance than MCARE/MCAID?

Redistribution (make up for lost money by using funds from private insurers. Money from well insured, wealthy to not so insured)


2 ways docs make money?

Direct services AND ancillary services (own labs, CT Scanners, etc)


Why is there an increased demand for nurses?

PCP shortage, aging US population AND aging nurses means more healthcare is needed, and creation of new jobs to do things like write rxs/notes, etc


AS the economy gets better, nursing shortage may be worse. Why?

Cuz if nurses don't have to work as much to support their lifestyle, they'll just cut down hours


Challenges to increasing nursing workforce?

Recruitment of new students, educational confusion, faculty shortage, and retention (cost of turnover)


Educational confusion?

You can get a bachelors or an associates (half time), or a diploma. Same license, but in a saturated are you need a BS.


Nursing faculty shortage?

Make much more money to be a nurse than to teach nurses.


Why nursing lack of satisfaction?

Schedule (nighttime, blegh), mandatory OT, burnout. Bad workplace setup. High pts per nurse ratio.


3 solutions for nursing?

Maximize scope of practice (equalize across states, cuz now different states require different oversight/authority despite same national licensing exam), increase level of education, and involve nurses in health care redesign


What makes you eligible for MCARE?

1) Over 65 2) Under 65, and chronically disabled (you may have SS disability benefits for 2 years).


What is covered as extra for dual eligibles?

MCAID covers gaps in MCARE coverage such as LTC, dental, eyeglasses, pays part of MCARE B premium, etc.


Explain how the govt factors into employment-based health insurance.

Fed Gov views premium payments as a tax-deductible business expense. Cuz employer is paying for part of the premium, it's like employee is getting tax-free income and the fed govt is subsidizing the insurance.