Study_Guide_Test_1_Spring_2023.pdf

Study Guide Test 1 Ch 1 Factors most contributing to premature death - Lifestyle And Behaviors (50%) - Genetic (20%) - Social and Environmental Factors (20%) - Medical Care (10%) Ch 2 Players/Place/Payment/Power for health care in 1900s 1950s and 2000 Changes in where services were provided in 195...

Study Guide Test 1 Ch 1 Factors most contributing to premature death - Lifestyle And Behaviors (50%) - Genetic (20%) - Social and Environmental Factors (20%) - Medical Care (10%) Ch 2 Players/Place/Payment/Power for health care in 1900s 1950s and 2000 Changes in where services were provided in 1950s as compared to 2000’s - Movement away from patient’s homes towards hospitals, doctors offices, and outpatient centers Modes of paying for health care- mode that is most prevalent- problem with this mode - Out of Pocket: individual directly pays the provider o Can be unpredictable due to frequency and cost o There has been an increase in out of pocket in order to control premium costs - Individual Private Insurance: individual pays directly to a health plan for a provider o Very expensive since there is no group discount - Employment-Based Private Insurance MostPopular j - o Started as a way for companies to incentivize workers during WWII wage controls o In response to increasing healthcare costs o Tax incentives for both Employers and Employees were put into place Government Financing and Subsidies: public insurance programs for privately operated health services o Combination of Federal and State run insurance programs o Improved financial access to care for some people but in turn aggravated the problem of rising costs elderly poor What are experience and community rating, which is better for people with high-cost health problems? - Community Rating: same insurance rate for everyone in the area o Better for people with high-cost health problems since they wouldn’t have to pay more for their insurance premium due to their increased usage - Experience Rating: setting insurance rates on the basis of a group’s actual healthcare expenses in a prior period, allows healthier groups to pay less health pay Blue Cross-Blue ShieldCB CBS - Blue Cross (BC) = Insurance plan covering hospital care giving choice of hospitals - Blue Shield (BS) = Insurance plan covering physician and other outpatient services young Moral hazard - If someone has an insurance plan that will cover everything, they will have increased unnecessary usage of healthcare since they do not have to pay for it Medicare A, B, C, D, Medicaid, and SCHIP- features- how are they financed, who is eligible, what benefits do they include, in which instances do consumers pay a premium? - Medicare Part A: Hospital Insurance o Financing: Social security taxes government collects from employers and employees o Eligibility: Over 65 years old, Disabled, Chronic Renal Disease, or ALS o Benefits: Hospitalization, Skilled Nursing, Home Healthcare, Hospice Care o Premium: None if they have paid into Social Security for 10 years but deductibles and coinsurance - Medicare Part B: Physician & Outpatient Services Insurance o Financing: Federal Revenues & Monthly Premiums o Eligibility: Anyone o Benefits: All Medically Necessary Services, Preventive Services, Outpatient Medications o Premiums: $135 (higher with >$85,000 income) and $185 deductible each year then a 20% coinsurance - Medicare Part C: Medicare subsidies for the premium of contracted private health plans with reduced provider networks to choose from forpatient o Financing: Federal Revenue o Eligibility: Anyone with Medicare o Benefits: Allows people to use private health plans at a lower premium cost o Premium: Subsidized private plan premium - - - Medicare Part D: Prescription drug coverage through private health plans o Financing: 73% Federal Revenue o Eligibility: Anyone with Medicare o Benefits: provides drug and medication coverage o Premium: $415 with 25% coinsurance for generic and 37% coinsurance for brand Medicaid: o Financing: State and Federal taxes o Eligibility: citizens with an income at or below 138% of the Federal Poverty Level and any other conditions set by individual states o Benefits: overall medical care coverage o Premium: None if they qualify under conditions o Not all providers accept Medicaid due to row reimbursement sometimeshard SCHIP: Medicaid companion program to cover healthcare for children tofindcare o Financing: State and Federal taxes o Eligibility: children in a family at or below 200-300% of the Federal Poverty Level o Benefits: overall medical care coverage o Premium: None if they qualify under conditions Effect of rising health care costs on low income people - Increase in Out-of-Pocket costs has created a regressive mode of financing - Lower income people tend to be sicker and thus have more out of pocket payments than the wealthier and healthier - High out of pocket payments means that low income people do not access healthcare Ch 3 Access and A and M text Reasons why the health care market not a normal market - Information Asymmetry: Patients, providers, hospitals, and insurers know different information that others don’t know - Insurance as Insulation: Cost-sharing by insurance hides the real cost from consumers - Conflicting Interests: Physicians may act as the patient’s agent and as someone who profits from provided care - Tax Subsidies: Market is distorted by subsidies provided to employers and employees - Failure of Competition: Individual nature of insurance plans and hospitals keeps them from competing as market goods - Suppliers are either legally or morally required to provide services Financial and non-financial barriers to insurance - Financial Barriers: o Lack of Insurance o Underinsurance insurancedoes notcover needed healthcare ▪ Coverage Limits ▪ Deductibles ▪ Copayments and Coinsurance ▪ Lack of long term care coverage - Nonfinancial Barriers o Primary Care Physician Shortage o o o o Physical Distance between Facilities and Patients (Ex. Rural areas) Language and cultural incompatibility between provider and patient Gender Ethnic background Who are the uninsured and reasons why people are underinsured? - Employed Uninsured: higher percentage of POCs and lower annual household income o Low pay o Working part time or multiple part-time jobs have hoursbutnotpositions many o Small firms that don’t offer health insurance with healthbenefits - Unemployed Uninsured: expensive ornot read o Has to pay 100% of premium on former employers plan after being paid off o Low income but ineligible for Medicaid IBRA Regressive, progressive forms of financing - Financing is based on where the different burdens are placed across income levels - Regressive: take a falling percentage of income as income increases o Ex. Out-of-Pocket payments - Progressive: take a rising percentage of income as income increases ex incometax Types of health insurance coverage- indemnity, HMO, PPO, POS, Consumer Driven High Deductible- features; benefits/negative aspects of each type of coverage - Indemnity: simplest and most popular in 1900s o The beneficiary has a fixed amount of cost-sharing regardless of which physician or hospital he or she visits no innetwork or outofnetwork o Still must pay premium and coinsurance - Health Maintenance Organizations (HMOs): most tightly integrated plan o Requires a PCP who is responsible for healthcare, making referrals to specialists, and approving medical treatment o Must pay copayment for services o Out-of-network care is not covered toreferrals o Pros: relatively inexpensive, emphasis on preventative care o Cons: limited choice of physicians, specialized care is difficult to access - Preferred Provider Organization (PPO): most-expensive premium but has the most freedom o Has a provider network (copay based) and non-network provides (coinsurance based) o Enrollees can self-refer to another physician, allows patients to self-direct care o PCP is not required o Providers are paid a discounted fee for services provided o Pros: wide choice of providers and hospitals, no specialist referral, allows for cheaper out-of-network costs - Point of Service (POS): HMO hybrid combining fee for service and pre-paid insurance o Requires PCP who is the “Point of Service” o Price is between PPO > POS > HMO intermediateprice o Pros: free to use non-network providers o Cons: co-payments for non-network careais high (50% coinsurance), specialized care referrals are difficult to obtain, paperwork required for out-of-network care reimbursement go - Consumer Driven High Deductible moneyrolls over o Include “tax free bank accounts” only used for medical expenses ▪ Health Savings Account (HSA): tax-free savings account to offset care cost, only with a HDHP used to pay for medical costs, coinsurance, and copays ▪ Flexible Spending Accounts (FSA): not tied to a high deductible account created by the employer to offset copay and coinsurance costs ▪ Neither HSAs or FSAs are required for business or insurance plans use or lose o High Deductible Plans with lower premiums 7 Most used Plan - Small Firms: 45% PPO - Large & All Firms: 46% PPO i Medicaid: consistentbutwas - Not all providers accept Medicaid due to low reimbursement n - State eligibility standards mean that care is not always available to those who need it - People have healthcare access intermediate between the uninsured and the insured - People are more likely to have regular source of medical care, get more preventive services, and report fewer delays in getting care compared to uninsured - People are more likely to have trouble obtaining medical care, prescription drugs, dental care, and eyeglasses compared to insured people - Difficulty finding a doctor because providers have low reimbursement rates and longer time for reimbursements doctorsdon'tacceptMedicaid many What is COBRA; benefits/limitations - Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) - Benefits: guarantees insurance at group insurance rates for 18 months for people who lose insurance because of divorce, job loss, death of working family member, or when a child is no longer a dependent - Limitations: Premiums may be unaffordable with little to no income Access to care issues for women - Dissatisfaction with physician care - Lower quality of preventative care and inappropriate care - Less likely than men to fill a prescription - More likely to be on Medicaid and difficulty finding a physician - Reduced access to care like abortion - Minority Women are at highest risk due to poverty, no high school diploma, no health coverage, no doctor visits, no personal doctor Models of health care: Medical, Behavioral, Holistic - Medical Model: Assumes the existence of illness or disease o Emphasizes clinical diagnosis and medical interventions to treat disease and disease symptoms o Definition of health assumes absence of disease or illness - Behavioral Model: Assumes that health results from interaction between the individual and the environment o “Complete physical, mental, and social well-being” Holistic Model: Emphasizes the well-being of all aspects of a person’s life and adds the spiritual dimension o Physical, Mental, Social, and Spiritual o Takes into account and emphasizes religious preferences Benefit of access to health insurance for employees in large firms vs. small firms - Large Firms: experience economies of scale and must pay less as a percentage of payroll to provide health insurance - Small Firms: higher cost to provide health insurance for employees but need it as an incentive to hire workers Ch 4 One factor contributing to health care inflation - Reimbursement System: how to pay for the services provided - Insurance companies determine reimbursement amount for services - Intersection between risk between provider, insurer, patient Units of payment- Physician and Hospital risks for providers and insurers related to each unit Procedure, Day, Episode, Patient, Time Physician Fee for service- who takes on the risk & Medicare Resource value based scale- why was it developed? - Fee For Service (FFS): o Usual, Customary, Reasonable (UCR): traditional fee for service where the doctor sets the price and the insurance provider pays ▪ Created a moral hazard since doctors could set payment unilaterally and there was no cost-sharing o Medicare Resource Based Relative Value Scale: fee is determined by estimating time, mental effort, judgement, skill, physical effort, and stress - - - ▪ Attempted to correct for bias of physician payments ▪ Has geographic differences o Fee Schedules or Discounted FFS: payer determined fees Episode of Illness: Specialists receive on bundled payment for the case or episode o Provider is at risk if they pay more for the services provided than the total bundle amount paid to them by insurance Capitation: an established rate to cover a person’s medical care for a specified time (Per member per month) o Physician Capitation: risk is if a patient consistently comes in during a month but good since it is a guaranteed billing o Primary Care Physician Capitation: adjustments for financial risk ▪ Carve-Outs: separate payments for immunizations, office tests, diagnosis or conditions, minor surgical procedures as a combination of capitation and FFS ▪ Makes sure that physicians still evaluate issues and know that they’ll get reimbursed o Risk Adjusted Capitation: meant to limit risk skimming by creating a higher rate for higher risks (ex. Elderly, chronic diseases) ▪ Challenge of setting fair rates based on patient health risks ▪ Physician is paid more to take care of this patient giving the patient increased access to care. o Merits of Capitation: ▪ Better ability to plan, manage and control costs through telehealth ▪ Improved care delivery as each patient has a PCP ▪ Stronger bargaining position to arrange best ancillary services and specialty service rates ▪ Can provide care without uncertainty of the cost and payment of services o Two Tiered Payment Model: Health Plan and the PCP o Three Tiered Payment Model: payment to intermediary group (IPA) ▪ Financial risk for diagnostic and specialty services are born by the IPA and spread across PCPs ▪ Bonuses transitioned from promoting decreased specialist use to quality measures in Pay for Performance ▪ Physician takes the risk Physician Payment by Time: salary based o Most evident in the public sector with VA, military, state, and community facilities o Private Sector has Staff model HMOs (ex. Kaiser) ▪ Group model HMOs: capitation contract with the IPA who pays slaray to physicians Reimbursement trend toward value based purchasing - Value = Quality + Patient Experience (based on surveys) + Cost of Care - Government withholds some payment towards doctors for Medicare and Medicaid until value benchmarks are met, if they are not met then the money is not given Medicare Resource Based Relative Value System- What is it? How did it improve on traditional fee for service? - Takes into consideration estimate time, mental effort, judgement, technical skill, physical effort, and stress - Attempted to correct for bias of physician payments - Geographic differences were also accounted for Cost containment focus in 1990s and in contrast now - 1910’s cost containment focused on: o Pressure to limit number and costs of services, with bundling services into one payment, shifting risk to providers o Traditional FFS was then replaced by fee schedules and rate negotiations - Current focus: o Era of blended payments with negotiation between prayers and providers and use of fee schedules for FSS o Ex. National Health Service - Larger problem with striking a balance between incentives for over treating and under treating