Healthcare Systems Exam #1

What percentage of total healthcare spending is attributed to chronic illnesses?

chronic illnesses make up 85% of health care costs

- these diseases can often be prevented with lifestyle choices

What percentage of total healthcare spending is attributed to healthy people?

The healthiest 50% consume only 3% of the nation's health care costs

What are the pros of universal healthcare?

- lowers health care costs for an economy (controls external party costs like hospitals/PT/clinics)

- forces hospitals and doctors to provide same standards of care at low cost

- eliminates administrative costs by eliminating need to deal with private insurance

What are the cons of universal healthcare?

- forces healthy people to pay for others' medial care

- without financial incentive, people may not be as careful with their health (people might overuse emergency rooms and doctors)

- most universal systems report long wait times for elective procedures

what can universal healthcare can and can't do?

What would the ripple effects be is universal healthcare was enabled?

- according to CRFB, the cost would be $28.0T

- would tax the rich and incorporations, etc and the rest would come from the working class increasing taxes heavily

- Our country's debt would increase

What are the key dates for Medicare?

1912 - original idea from Teddy Roosevelt

1948 - large efforts from Harry Truman

1950 - social security officials realized American and were facing a health care crisis

1965 - Medicare legislation after efforts of JFK was signed by Lyndon B Johnson

1966 - Medicare was implemented

What are the key dates for Medicaid?

1965 - Medicare was enacted as an entitlement

What is the coverage total of Medicare?

15% of total federal spending (total amount of people)

ask???

What is the coverage total of Medicaid?

88 million are covered

1 in 5 individuals

used to be for disabled and women/children, but now has expanded, more for low income

What is the provenance of Medicare?

- Thought originated from Teddy Roosevelt in 1912 and was redressed in the 50s when they realized older Americans were facing a health care crisis

- JFK brought back the idea or health coverage for Americans over age of 65 but was not put into place until 1965 when Lyndon B Johnson signed legislation

What is the provenance of Medicaid?

- Enacted in 1965 as companion legislation of Medicare

- established an entitlement/right of an individual who meets certain poverty/disability levels

- provided federal matching grants to states to finance care

- focused on single parents with dependent children, aged, blind, disabled

What are the key differences between Medicare and Medicaid?

Medicare is for people over age 65, U.S. citizen, received SS or railroad retirement, are kidney dialysis or kidney transplant patient

Medicaid is for low-income persons who are aged, blind, disabled, members of families with dependent children and certain other pregnant women and children

- if you qualify for Medicaid and are 65 years and older can most likely qualify for Medicare too

More????

What is the WHO's view on what should be included in universal healthcare?

Includes 3 related objectives:

- equity in access to health services

- quality of health services should be good enough to improve the health

- people should be protected against financial-risk, ensuring cost doesn't put people at risk of financial harm

What is the Pew Research Institute known for?

centrist, unbiased and high quality information

What typically drives public policy changes?

- patients (the people)

- providers

- practice regulations (state levels)

- third party payers (insurance)

- industry

- the economy

- the government

Why is public policy change slow going?

??? ask about this one

What are the general basics of the Duke Technical Standards for admissions? Specifically with language requirements

- minimum physical, emotional, cognitive, and social capacities to complete all program requirements either directly or through reasonable accommodations.

- Students must possess all of the abilities described in the five categories (observation, communication, motor and sensory functions, intellectual-conceptual, integrative, and quantitative abilities and behavioral and social skills)

language requirements: must be able to communicate effectively and sensitively in English both in person and in writing,

must be able to clearly and accurately record information and interpret verbal and nonverbal communications.

What is an HMO?

Health Maintenance Organizations (HMOs)

- health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO

- they CONTROL COSTS they are willing to pay

- it generally won't cover out-of-network care except in an emergency

What is a PPO?

Preferred Provider Organizations (PPOs)

- health plan that contracts with medical providers such as hospitals and doctors, to create. network of participating providers

- insured individual pay less if they use providers that belong to the plan's network

What is Exclusive Provider Organizations (EPOs)

- a hybrid health insurance plan in which a primary care providers is not necessary, but health care providers must be seen within a predetermined network

- out-of-network care is not provided, and visits require pre-authorization

What is Point-of-Service (POS) plans?

- has some pop the qualities of HMO and PPO plans with benefit levels varying depending on whether you receive your care in or out of the health insurance company's network

ex) working for hybrid teaching organization

What are Accountable Care Organizations (ACO)?

- healthcare reform efforts to transition from fee-for-service models to value-based care, improving outcomes and reducing unnecessary costs

- structure varies

- HCP form a collaborative network that is responsible for the health outcomes of a defined group of patients

- key goals: enhance patient care, promote preventative measures, and achieve cost efficiencies

What are High-deductible health plans (HDHPs)

- plan with a higher deductible Thant a traditional insurance plane

- monthly premium is usually lower, buy you pay more health care costs yourself before the insurance company starts to pay its share (your deductible)

What are common terms in private insurance?

copays

deductibles

coinsurance

secondary insurance

monthly premiums

maximum out of pocket costs

what are copayments?

- fixed amount you pay each time you visit a health provider

- designed to reduce unnecessary visits since it costs you each time you visit a provider

what are deductibles?

- specified amount of money that the insured must pay before an insurance company will pay a claim

ex) with $2000 deductible, you pay the first $2000 of covered services yourself, after you pay your deductible, you usually pay only a copayment or coinsurance for covered services - your insurance company pays the rest

what is coinsurance?

a type of insurance in which the insured pays a share of the payment made against a claim

what is secondary insurance?

a type of insurance (that isn't your primary), you can purchase to pay any unpaid balance (that isn't a deductible)

what are monthly premiums?

fixed amount you pay regularly (usually monthly) to your insurance company to keep your health coverage active

what are maximum out of pocket costs?

- the most you have to pay for covered services in a plan year

- after you spend the amount of deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits

How does the ADA frame reasonable accommodations?

A change that accommodates employees with disabilities so they can do the job without causing the employer "undue hardship" (too much difficulty or expense)

they are nearly never provided when it risks how patients are managed

What are the principle elements of the Beveridge system?

health care is provided and financed by the government through tax payments, just like police force or the public library

Funding source: tax funded government system

Providers: mostly government owned facilities; many public employees

Coverage: universal

Cost to Patients: free or very low cost at point of service

Ex) UK, Italy, Spain, VA system (US), Cuba - extreme application

What are the principle elements of the Bismarck system?

an insurance system, the insurers are called "sickness funds", usually financed jointly by employers and employees through payroll deduction

Funding source: employer-employees payroll contributions to nonprofit "sickness funds"

Providers: mostly private providers

Coverage: Universal (mandatory insurance)

Cost to patients: low out of pocket; regulated prices

Ex) Germany, France, Japan, Belgium

within this model, even though employees pay a premium, employers pay more than employees for healthcare (about 70% of it) - on test

What are the principle elements of the National Health Insurance system/SinglerPayer?

- has element of both Beveridge and Bismarck

- uses private sector of providers, but payment comes from government-run insurance programs hat every citizen pays into (no financial motive to deny claims and no profit makes admin easier)

Funding source: single government insurer; funded by taxes r premiums

Providers: mostly private providers; government pays the bills

Coverage: Universal

Cost to Patients: low cost; strong cost control via single payer (SLOW)

Ex) Canada, Taiwan, South Korea

Out of Pocket Model/Private Insurance System

- no government supported system

- people pay for use of healthcare

Funding source: individual pay directly for care

Providers: private providers

Coverage: no universal coverage

- Cost to patients: high cost, access depends on ability to pay

Ex) low income countries; informal system

Compare and Contrast the health insurance models

- The main 3 are Universal coverage, out of pocket model is not

- Relatively low cost to patients for main 3

- Beveridge and National Health insurance funding course is mostly government

- Bismarck providers are mostly private

Beveridge Model: larger taxes for everyone to cover everyone, heavily regulated, work for 70-80% of salary

Bismarck Model: unemployed - uninsured, purchase insurance outside employer, health plan is dictated (HMO, PPO)

National Health Insurance Model: reduces cost, but there is less incentive for providers - hard to get appointment with specialities

What are the different alternative forms of healthcare models?

- value-based care

- accountable care organizations (ACOs)

- patient-centered medical homes (PCMHs)

- Direct primary care (DPC)

- Integrated Care Models

- Tailor Care

- TEAM model

TEAM Model

solve issue of fragmented care and encourages

promote collaboration with ACOs, episodic care for certain conditions/surgeries

What is the GINI coefficient? What does it represent?

Perfect and complete sharing of wealth = coefficient of 1

- looks at the sharing of wealth in a country

- lower sharing of wealth moves closer to Lorenz curve closer into quadrant

What are examples of the GINI coefficient provided?

lower coefficient = more evenly distributed

ex) Slovenia, Czech Republic, Norway

higher coefficient = less evenly distributed

ex) South Africa, Haiti

U.S. is 45 in he middle

What are the different Parts of Medicare?

Part A, B, C, D

What is Medicare Part A and what does it cover?

Hospital Insurance

- provides coverage of inpatient hospital services including SNF, home health services and hospice care

you have worked over 40 quarters n the US, are 67 and were hospitalized with the "COVIN" which part will cover your stay?

Part A

What is Medicare Part B and what does it cover?

Medical Insurance

helps pa for cost of physician services, outpatient hospital services, medical equipment and supplies and other health services

- outpatient oriented

- monthly premium

What is Medicare Part C and what does it cover?

Medicare Advantage Plans

- Part A + Part B + Part D (usually)

- functions specifically like part B, but allocates medications and other items not covered for as payment for unpin the billing process

- pay premium each month, coordinate care for you

What is Medicare Part D and what does it cover?

Medicare prescription drug coverage

- monthly premium

you received prescription for tramadol. which part will cover your prescription cost

part D

your grandmother who is eligible and is 84, fell at home. she was hospitalized for 10 days which part?

Part A

you are 72 and tor your meniscus. you are referred to PT which part?

Part B

you are 68 qualify for medicare, was convinced to purchase managed care plan through Aetna? Which part?

Part C

you are 74 and suffer a stroke. Symptoms Are marginal referred to SLP. Which part?

Part B

What is the misinformation effect?

term used in the cognitive psychological literature to describe both experimental and real-world instances in which misleading information is incorporated into an account of a factual or historical event

- seen a lot in politics, think it is correct

disinformation

the deliberate repositioning of information for gain

What are left-leaning news agencies?

- MS NBC

- CNN

- CBS

- Politico

- NPR

- BBC

- PBS

What are right-leaning news agencies?

- Fox

- New York Post

- Boston Herald

- Newsmax

What are centrist (bipartisan) news agencies?

- BBC news

- Pew research

- Wall Street journal (news)

- Forbes

- Newsweek

- the Hill

What is the Single Payer Model? Why is it similar to a universal health model?

Model that improves quality and reduces overall costs

- both have similar limitations

How do insurance companies undermine the 80/20 rule?

What is the 80/20 rule also called?

Medical Loss Ratio