Test 1 Flashcards

Question

What are the different types of health insurance coverage plans?

Answer 1

1. Indemnity Plans 2. Managed Care Organizations - Health Maintenance Organizations (HMO) - Preferred Provider Organizations (PPO) - Point of Service Plans (POS) 3. Consumer-Driven Health Plans - Health Savings Account (HSA) - Flexible Spending Account (FSA) - Health Reimbursement Accounts (HRA)

Answer 2

Pros: No paperwork, inexpensive, focuses on preventive care. Cons: Limited physicians, specialized care is harder to get, out-of-network care is not covered.

Answer 3

Most expensive but offers the most freedom, network, and non-network providers. PPOs attract people who want to avoid referrals for specialists and prefer out-of-network care options.

Answer 4

A hybrid between HMO and PPO, combining prepaid insurance with fee-for-service. Requires a PCP, more flexible than HMO but less than PPO. Pros: Free to use non-network providers. Cons: High copayments for non-network providers, referrals needed, and paperwork required for out-of-network reimbursement.

Answer 5

High-deductible, low-premium plans with tax-free bank accounts used only for medical expenses (e.g., HSAs and FSAs).

Answer 6

HSA: Tied to high-deductible health plans, tax-free, accrues interest, carries over year to year, and funds are portable but taxed if withdrawn for non-medical use. FSA: Not tied to high-deductible plans, up to $3650 can be contributed, but funds must be used by the end of the year or are forfeited.

Answer 7

COBRA: Provides group-rate insurance for 18 months after losing coverage, but premiums are unaffordable for many. Medicare: Covers individuals over 65 and those with certain disabilities. Medicaid: Provides care for individuals at or below 138% of the federal poverty level.

Answer 8

Cost-sharing involves patients paying part of healthcare costs through deductibles, copayments, or coinsurance. According to the RAND study, patients with cost-sharing plans used fewer inappropriate services but also fewer appropriate services, leading to poorer health outcomes.

Answer 9

Primary care physician shortage Finding physicians who accept insurance Scheduling appointments Physical distance (especially in rural areas), Transportation Language and cultural barriers Gender Ethnic background.

Answer 10

Public health interventions, medical care, socioeconomic status, and age.

Answer 11

The study examined British male civil servants and found a strong association between lower employment grade and higher mortality rates. Men in lower-grade jobs had a mortality rate three times higher than those in higher-grade jobs.

Answer 12

Dissatisfaction with physician care Lower quality of preventive care Inappropriate care Difficulty affording prescriptions Reduced access to abortion services Minority women, in particular, face higher rates of HIV/AIDS and barriers to healthcare access due to poverty and lack of education.

Answer 13

Increased payment to PCPs, restructured payment systems, reduced documentation requirements, and building stronger teams with non-clinical staff to support healthcare delivery.

Answer 14

Medicare uses Relative Value Units (RVUs) to set clinicians’ reimbursement fees.

Answer 15

Fee-for-service (FFS) Per diem (daily rates) Episode of illness payments (bundled fees) Capitation (payment per patient) Global budgets (aggregated payments)

Answer 16

Calculates fee-for-service payments based on time, effort, and geographic factor (Set by Medicare)

Answer 17

Usual, Customary, and Reasonable (UCR) fees

Answer 18

single, bundled payment for all services related to a specific illness or procedure (e.g., surgery or obstetrics)

Answer 19

Physicians are paid a set amount per patient for a specific time period Financial risk on the provider Adjustments are made for financial risk, such as carve-outs for specific services and risk-adjusted capitation for patients with higher medical needs.

Answer 20

Physicians in public sector facilities (e.g., VA, military) and staff-model HMOs often receive salary-based payments. In group-model HMOs, physicians may be salaried through capitation contracts.

Answer 21

Two-Tiered: Involves a health plan and a primary care physician (PCP). Three-Tiered: Adds an intermediary group (Independent Practice Association - IPA), which bears financial risk for specialist services.

Answer 22

Better ability to plan and control costs. Nurses and assistants can provide “virtual visits.” Improved care delivery, as each patient has a primary care provider (PCP). Providers can negotiate better rates for specialty and ancillary services.

Answer 23

Lump-sum payments based on the patient’s diagnosis Hospitals bear the financial risk of length of stay

Answer 24

Private companies contract with CMS to manage Medicare spending for a group of patients. The CMS pays a capitated rate to the MA plan, which then contracts with providers. While it typically uses FFS reimbursement, Medicare Advantage costs Medicare more than traditional plans.

Answer 25

Pressure was placed on providers to limit the number and costs of services. Bundling services into one payment and shifting risk to providers was a common approach. Traditional FFS was replaced by fee schedules and rate negotiations to contain costs.

Answer 26

Global budgets for overhead costs. Capitation payments for general services (per member, per month). Fee-for-service payments for specific prevention services. This system shifts risk away from payers and toward physicians.

Test 1 Flashcards

(50 cards)