Healthcare Economics Test

Blue Cross

provides prepaid plans to cover hospitalization costs

Blue Shield

groups of physicians used to cover physician service fees

Social Security Act of 1965

The most significant change in government healthcare financing which approved the Medicare and Medicaid programs

government institution

receives most of its funding from local, federal, or state sources

voluntary nonprofit institution

receives federal, state, and local tax exemptions in exchange for providing community benefits

proprietary institution

for-profit institutions usually owned by corporations

government plans

healthcare plans funded by the government

TRICARE

an insurance system for active and retired service personnel

Medicare

healthcare program for older Americans 65 or older; uses prospective payment system

prospective payment system

pays healthcare provider a fixed amount based on diagnosis or specific procedure, rather than actual cost

Medicaid

offers insurance to low-income and disabled people

Medicare Part A

inpatient hospital care not requiring premium

Medicare Part B

outpatient care services

Medicare Part C

allows people to buy into private health insurance

Medicare Part D

gives prescription drug coverage

Medicare Advantage

another name for Medicare Part C

1970

the year managed care was started

health insurance

in place to protect yourself if you get sick or injured

COBRA

gives people the right to continue a work-based group plan after a job loss, death of spouse, divorce, or eligibility loss for dependent coverage

26 years old

the age a person can stay on their parents plan for

premium

the monthly amount paid to a private insurance company for health insurance coverage

deductible

the money a person must pay yearly before an insurance company provides benefits

out-of-pocket

the total amount of money payed for care that is not covered by insurance

copay

a flat fee that many health insurance plans require patients to pay each time they receive health care service.

co-insurance

the portion of medical costs a patient may still have to pay once deductible has been payed

out-of-pocket max/limit

the highest out-of-pocket amount that can be paid before insurance pays for everything including copay and co-insuarnce.

in-network provider

a health care provider that has a contract with a managed care insurance plan

out-of-network provider

a healthcare provider who is not in a particular managed care health insurance plan

50+ employees

a work place is required to get employee health insurance benefits if they have this many employees.

Affordable Care Acts

takes into account age, location, tobacco use, individual or family plan, and plan category to determine premium

Health Savings Account (HSA)

a monetary account commonly paired with a high-deductible health insurance plan that allows individuals to pay for qualified medical care using pre-tax dollars until they meet their deductibles. Any funds remaining at the end of each year are rolled over and can be saved for future use.

Flexible Spendings Account (FSA)

a monetary account, offered through an employer, into which money is put through payroll deductions, before it is taxed. Funds can be withdrawn for qualified medical expenses as needed, but the funds must be spent each year.

Diagnostic Related Groups (DRGs)

a classification system used by Medicare and Medicaid to determine payment for health services based on diagnosis, surgical procedure, age, other information

Direct payment

the act of paying for health care with one's own money

gatekeeper

a physician who not only delivers primary care services, but also makes referrals for specialty care.

healthcare cost containment

measures designed to lower health care costs that aim to create an affordable health care system for all Americans.

managed care

a type of health insurance plan that establishes predetermined rates for services with health care providers such as doctors and hospitals, and puts providers in the position of managing patients' use of health care.

Health Maintenance Organization (HMO)

a health insurance plan that provides coverage only if the care is delivered by a member of the plan's hospital, physician, or pharmacy panel.

point-of-service (POS)

a physician-coordinated health insurance plan that combines characteristics of both HMO and PPO plans

Preferred Provider Organization (PPO)

a health insurance plan that allows patients to receive care from a non-plan provider, but requires them to pay a higher out-of-pocket price if they do so.

private insurance

a health insurance system that allows individuals to obtain group health benefits through an organization, such as an employer, a union, or an association

resource utilization

making better use of health care resources to cut costs

utilization review

a process in which an insurer reviews decisions by physicians and other providers about how much care to provide.

How do you calculate cost after Insurance

Deductible > Copay > co-insurance >

US healthcare spendings projected growth between 2008-2018

6.2 percent

percent of spendings going to healthcare

20.3 percent

examples of voluntary non profit institutions

clinics, services for those who cannot afford it

examples of proprietary institutions

usually a "chain", multiple facilities in multiple states

examples of government institutions

military treatment facilities, veteran affairs hospitals (VA), public or government funded hospitals, state mental hospitals, state rehabilitation facilities

how is healthcare paid for in the us?

government plans, private insurance, direct payment

how do most americans obtain health insurance?

through their employer

what are HMO, PPO, and POS plans?

manage care plans

how are managed care plans different from conventional plans?

managed health care plans are dependent on a network of health care providers, doctors, and facilities that establish a contract with an insurance provider.

How do DRGS affect the amount paid to providers for health care services?

generally, services will cost less with DRGs, which lower the amount of money that healthcare providers will receive.

why should healthcare workers practice resource utilization?

To conserve resources, time, and energy to be able to treat more patients more efficiently.