US Healthcare System

Healthcare

Efforts made to maintain, restore, or promote someones physical, mental, or emotional well-being especially when preformed by trained licensed professionals

Reimbursement

Process of payment fro services rendered

Services

Health promotion, disease prevention, diagnosis and treatment, rehabilitation (medicine, dentistry, pharmacy nursing, physical therapy)

Professions

Work done by a variety of professions (midwifery, optometry, audiology, psychology, occupational therapy)

Systems/Models

4 maintypes - composed of - services consumers, personnel, and payment

Levels of care

Primary, secondary, tertiary, and quaternary

Businesses

“Healthcare sector” this includes any business that provide medical services, manufacture medical equipment or drugs, provide medical insurance, or help faclitate the provision of healthcare to patients

Primary care

1st or initial level of care within the healthcare system, consists of PCPs, typically consists of common illness diagnosis, chronic disease state management, preventative health

Secondary care

A more specialized level of care that involves seeing a specialist, typically requires a referral from PCP, ex. cancer treatment, orthopedic treatments, dermatology, podiatry, urology

Tertiary care

A highly specialized level of care (in comparison to the 1st two), typically involves inpatient management, ex. life-threatening situations, burn units, major cardiac surgeries, intensive care units, trauma units, transplant units, neuro units

Quaternary care

Highest level of speciality, typically covers unique or niche medical issues, often only offered at a small number of centers

Palliative care

Help mange discomfort, pain, nausea, and other side effects of therapy or disease process, can occur at any time during the disease process

Hospice care

Subtype of palliative care, end of life care, typically six months or less, treat person and symptoms, not the underlying disease process

2 main components of healthcare spending

# of services used (utilization), amount charged per service (fee)

Beveridge model

Government owns/operates/employees/hospitals/clinics, paid for by taxation

Bismarck model

Healthcare is privately funded through employees and employers’ required contributions to a general fund for healthcare reimbursement

National health insurance model

Mix of previous 2, healthcare is paid for by governement via taxation but is delivered/provided through mix of public and private hospitals/clinics

Out-of-pocket model

Also called direct-fee system, depending on insurance status, the patient pays all or part of cost for medical care

Emergency Medical Treatment and Labor Act (EMTALA)

Emergency rooms must treat patients regardless of their ability to pay

CHIP

Childrens health insurance program, covers uninsured children that are part of families that dont qualify for medicaid

ACA (“obamacare”)

Patient protection and affordable care act, and attempt to make insurance more accessible

Medicaid

Joint federal and state program that helps cover medical costs for people with limited income/resources, eligibility requirements vary from state to state

Medicare

Federal health insurance program for people 65 or older or with certain disabilities/conditions, set standards fro costs and coverage, same in each state

Medicare: Part A

Covers inpatient or hospital care

Medicare: Part B

Covers outpatient or medical care

Medicare: Part C

Offers an alternative way to receive medicare benefits such as through a medicare advantage plan - offered by private insurance companies

Medicare: Part D

Covers prescription drugs

Deductible

Amount you could owe during a coverage period (usually one year) fro covered health care services before insurance plan begins to pay

Co-insurance

Your share of costs of a covered health care service, calculated as a percent of the allowed amount for the service, you pay the coinsurance plus any deductibles you owe

Copayment

A fixed amount you pay for a covered health care service, usually when you receive the service

Exclusion

Conditions or other medical items/procedures that are not covered by the insurance plan

In-network vs out-of-network provider

Providers facilities that have or dont have a contract with your health plan to provide services for plan members at certain costs, out of network typically is more costly

(prior) authorization

Obtaining approval from the PCP and health plan prior to receiving health care services, such as visiting specialists, obtaining radiology scans, and undergoing surgical procedures

Claim

A claim is a request for payment for services and benefits you received, basically the medical term for a bill

Health maintenance organization (HMO)

HMOs provide care through a specified network or doctors and hospitals

Health savings account

Set aside pre-tax dollars for medical expenses, such as copayments, deductibles, medications etc or save money for future medical expenses, have to have a high deductible plan

Health insurance portability and accountability act (HIPPA)

Expands your health care coverage if you lose your job or if you move from one job to another, changes legal and regulatory environments governing the delivery, and payment of healthcare services, security, and confidentiality of patient health information

PBMs (pharmacy benefit managers)

Companies that manage prescription drug benefits on behalf of health insurers, medicare part D drug plans, large employers, and other payers