NHM 340 - Healthcare Systems and Policy (M5)

Categories of Health Insurance and Percentage of U.S. Population Enrolled

What are the two general categories of health insurance in the U.S.?

Private and Government/public health insurance

What type of private health insurance includes indemnity or traditional fee-for-service insurance?

Indemnity or traditional fee-for-service insurance

What type of private health insurance focuses on managed care?

Managed-care insurance

What type of private health insurance allows consumers to direct their own health care spending?

Consumer-directed health plans

What is the Medicare Program?

A government/public health insurance program for individuals aged 65 and older or with certain disabilities

What is the Medicaid Program?

A government/public health insurance program for low-income individuals and families

What is the Military Health System?

A government/public health insurance program for military personnel and their families

What does CHIP stand for?

Children's Health Insurance Program

What are individual state health plans?

Health insurance programs managed by individual states

What are indemnity or traditional fee-for-service plans?

They are insurance plans that charge for each service rendered.

What percentage of insurance coverage today is accounted for by private insurance?

Only a small percentage.

What do proponents of private insurance prefer?

Greater flexibility and unrestricted access to health care providers and facilities.

What do critics claim about fee-for-service plans?

They encourage physicians to provide unnecessary services.

What is managed-care insurance?

Insurance that tries to limit the use of health services, reduce costs, or both.

What are some types of managed-care insurance?

Health maintenance organizations (HMOs), Preferred provider organizations (PPOs), Point-of-service plans (POSs), Exclusive provider organizations (EPOs).

What is the presumed goal of managed care?

Improved quality of care with decreased costs.

What percentage of coverage for employees is accounted for by managed care?

Around 99%.

What are consumer-directed health plans?

Plans that combine a high-deductible health plan (HDHP) with a tax-advantaged health reimbursement arrangement (HRA) or health savings account (HSA).

How do enrollees use a health savings account (HSA)?

To pay for a portion of their health expenses.

What do proponents of consumer-directed health plans contend?

Enrollees seek lower-cost care and only seek care when necessary.

What do critics state about consumer-directed health plans?

Employers may use these to shift the cost of coverage to employees.

What are the two major public health insurance plans in the United States?

Medicare and Medicaid

Which federal agency is responsible for administering Medicare and Medicaid?

The Centers for Medicare and Medicaid Services (CMS)

What does CHIP provide?

Health coverage to uninsured children

What government agency provides health care services to veterans?

The Department of Veterans Affairs (VA)

What service includes the Indian Health Service?

The Public Health Service

Which department provides health care services to military personnel and their families?

The Department of Defense (including TRICARE)

What types of facilities provide health care services in the public sector?

Public hospitals and community health centers

What programs provide health services at the state and local level?

State and local public health programs

What program pays benefits to workers injured on the job?

Workers' compensation

What are common coverage gaps in public health insurance?

Prescription drug coverage and skilled nursing/long-term institutional care

What type of policy helps cover gaps in Medicare?

Medigap policy from private insurance companies

What is Medicare, Part C also known as?

Medicare Advantage

What are the eligibility requirements to join Medicare Part C?

The individual must have Medicare Part A and Part B

Who are the uninsured in America?

Working poor, self-employed, early retirees, and unemployed

What percentage of all Americans are uninsured?

13%

What type of medical care do uninsured individuals often use?

Hospital emergency room care

What do uninsured individuals often do regarding treatment?

Delay getting treatment

What is a consequence of uninsured individuals delaying treatment?

They later require more expensive medical services

How much was spent on health care services and products in the U.S. in 2013?

$2.9 trillion

What is a major contributor to the high cost of health care related to managing insurance?

Administration of insurance process

What practice in medicine contributes to the high cost of health care by avoiding potential legal issues?

Practice of defensive medicine

What type of costs contribute to the high cost of health care related to legal accountability?

Professional liability costs

What are the three trends characterizing efforts at cost containment in healthcare?

1. Move away from traditional fee-for-service to managed care models.

2. Companies managing employee healthcare through self-insured plans.

3. Payers setting reimbursement restrictions and limitations.

What is the Prospective Payment System (PPS) based on?

Diagnosis related groups (DRGs).

What factors are used to classify patients in the Prospective Payment System (PPS)?

Principal diagnosis, secondary diagnosis, age, sex, and surgical procedures.

What does each Diagnosis Related Group (DRG) have assigned to it?

A relative weight reflecting the cost of care.

What coding system is used in the Prospective Payment System (PPS) to classify diseases and diagnoses?

ICD 10-CM.

What has the Prospective Payment System (PPS) resulted in an increased focus on?

Outpatient services and preventive medicine.

Why are outpatient services emphasized in the Prospective Payment System (PPS)?

They are less costly than inpatient care.

What percentage of the population do baby boomers make up?

More than one-fourth

What percentage of the population is expected to be over 65 by 2030?

21%

What can be expected to rise due to demographic trends?

Demand for care

What type of disparities are highlighted in demographic trends?

Racial and ethnic disparities

Which population is expected to increase according to demographic trends?

Hispanic population

What is one of the goals of Healthy People 2030?

To eliminate health disparities

What does Healthy People 2030 aim to achieve in addition to eliminating health disparities?

Health equity

What is a key factor that Healthy People 2030 aims to improve?

Health literacy

What do most industrialized countries, except the U.S., have regarding health care?

National health care programs

How is health care coverage characterized in most industrialized countries?

It is universal and uniform

How are health care costs typically covered in most industrialized countries?

By tax revenues or a combination of individual/employer premiums and government subsidization

What is the goal of Healthy People 2030?

To decrease racial/ethnic and other health disparities

What types of outcomes will Healthy People 2030 track in relation to demographic factors?

Rates of illness, death, chronic conditions, behaviors, and other types of outcomes

Which demographic factors will Healthy People 2030 consider when tracking health outcomes?

Race and ethnicity, gender, sexual orientation, disability status or special health-care needs, and geographic location (rural and urban)

What is the Affordable Care Act?

A health care reform law enacted in 2010.

What does the Affordable Care Act aim to reduce?

The number of people who are uninsured.

How does the Affordable Care Act improve the health insurance system?

It makes the system work better for all consumers.

What transformation does the Affordable Care Act promote in health care?

It transforms delivery and payment systems to get better value.

What is the focus of health care reform according to the Affordable Care Act?

It reorients focus to prevention and primary care.

What role do nutrition protocols play in health care reform?

They serve as frameworks to help practitioners in the assessment, development, and evaluation of nutrition interventions.

What are the components of the scope of dietetics practice?

Nutrition assessment, counseling, and education.

What is involved in the research aspect of dietetics practice?

Development and evaluation of nutrition guidelines.

What administrative tasks are included in dietetics practice?

Management of time, finances, personnel, etc.

What is evaluated in community nutrition programs?

The effectiveness of nutrition counseling/education and community nutrition programs.

What do community nutritionists need to compete for?

A fair share of the health-care dollar.

Conflicting Healthcare Expectations Figure

What has been the legislative priority of the Academy since 1992?

Inclusion of medical nutrition therapy as a covered benefit in health care delivery.

What is the focus of the Academy regarding medical nutrition therapy?

Securing reimbursement under existing federal insurance programs.

Under which part of Medicare is medical nutrition therapy currently covered for selected recipients?

Part B.

For which conditions is medical nutrition therapy covered under Medicare for selected recipients?

Diabetes and renal disease.

What is the Academy of Nutrition and Dietetics actively trying to do regarding medical nutrition therapy coverage?

Increase coverage through legislation for other conditions, including prediabetes, obesity, hypertension, and eating disorders.

What will be one of the strongest factors affecting health care?

The paradigm shift from sickness to wellness.

What will medical education need to do in the future?

Medical education will have to change.

How must health care change in the future?

It must change from a system based on treatment of acute conditions to disease prevention and health promotion.

What role must nutrition services play in future health care?

Nutrition services must be part of preventive care.

What should all practitioners document regarding their nutrition programs?

They should document cost-effectiveness to support the integration and utilization of nutrition services in preventive care.