HMP 401 - Exam 2 (Chapters 6-10)

6 - Mental health in the US

About 44.7 million adults have some form of mental illness that may severely affect their quality of life or even become life-threatening

6 - Most organizations that provide mental health services are

**NOT** for profit

6 - What percentage of community hospitals have a dedicated psych unit?

25% to 30%

6 - What are the two most commonly used mental health providers?

psychiatrists (medical doctors) and psychologists

6 - Why does the US face a lack of mental health providers?

decreasing number of psychiatric residencies, low job satisfaction, and lower earning potential.

6 - Dual diagnosis

when a patient has both mental illness and substance abuse disorders

6 - Suicide in young people

Suicide is one of the leading causes of death among young people, and more than 90 percent of children who commit suicide have a mental health condition. The United States has the highest rate of death from mental illness of any other industrialized country.

6 - What percentage of Americans money is spent on prescription drugs?

27%

6 - What percentage of Americans money is spent on outpatient treatment?

35%

6 - How much of Americans money is spent on mental health treatment?

$186 billion/year

6 - Why is the use of mental health services much lower among minorities?

lack of convenient care to quality mental health

7 - What is the public interest (group) theory?

It says that government intervenes in the best interest of society to promote efficiency and equity in the market.

7 - What is the special interest (group) theory?

It defines special interest groups work to promote societal and business causes

7 - What is one of the most regulated industries in the US?

Healthcare

7 - What are the goals of licensure?

__Protect__ the public from unscrupulous, incompetent, and unethical practitioners

__Assure__ the public of a level of minimum of competence from healthcare providers

__Provide__ a mechanism to discipline providers who fail to comply with professional standards

7 - What is the largest federal healthcare agency?

The US Department of Health and Human Services (HHS)

7 - How much does the US spend on public health?

about $12 billion a year (that is really not that much)

full capitation

A payment method in which a fixed amount is paid to __an organization__ to provide __a comprehensive set__ of healthcare services for a set period of time

partial capitation (sub-capitation)

A payment method in which an organization is paid a fixed amount to provide __a select set__ of healthcare services for a set period of time

bundle payments

A payment method in which healthcare __providers__ are paid a set amount __for an episode-based or cycle__ of care, aka: case rate, package pricing, global payment) (e.g., hip surgery)

7 - How does the gov’t influence healthcare?

By being major purchasers of care

7 - How does the gov’t own and operate healthcare services?

As a provider

7 - How does gov’t play a role for public/social insurance programs (ex. medicare/medicaid)?

As a financer/funder

7 - Who is eligible for medicare benefits?

>65 or those with disabilities that are

7 - Medicare Part A

Part A - pays for inpatient hospital, skilled nursing facility, some home health, and hospice care costs. Part A is funded/financed primarily through a payroll tax by employers and employees.

7 - Medicare Part B

Part B - pays for physician, outpatient, preventive, and some home health services. Part B is funded primarily by general taxes and Part B premium

7 - Medicare Part C

Part C - also known as Medicare Advantage, allows Medicare enrollees to join a private managed care organization (MCO) health plan. Those who enroll in Part C pay a monthly premium.

7 - Medicare Part D

Part D - pays for prescription drugs benefits for Medicare beneficiaries. Part D is funded through general taxes, monthly premiums

7 - Medicaid - state-based program that is paid/financed for jointly by state and federal governments

low income, household size, disability, family status, among other factors

7 - What is CHIP?

Children’s Health Insurance Program

7 - What is EMTLA?

Emergency Medical Treatment and Labor Act

7 - What does EMTLA do?

requires emergency treatment regardless of ability to pay**;**  __**to prevent “patient dumping,”**__  as many private hospitals had long turned away patients who were uninsured and could not pay for their care out-of-pocket

7 - What is HIPAA?

Health Insurance Portability and Accountability Act

7 - What does HIPAA do?

protects the privacy and security of patients’ health information

7 - What is BBA?

Balanced Budget Act

7 - What does BBA do?

created in 1997, which expanded Medicare programs and children’s health insurance

7 - What is the ACA?

Affordable Care Act

7 - What does the ACA do?

increased subsidies for the poor and standardized health insurance offerings, among many other provisions

8 - What do healthcare economics primarily consider?

__the allocation__ of resources and __the efficient__ use of resources

8 - What is diminishing return/the law of diminishing return?

A suggestion to improve health, we only need to add more resources. Only works up to a point, but past a certain level, the addition of more resources produces smaller and smaller returns

8 - What is opportunity cost?

the value of a resource when it is employed in its next-best use (trade-off)

8 - What are externalities?

secondary impacts or a side effect on others

8 - What is demand?

* Consumer willingness to purchase goods and services at various prices


* An increase in price will reduce quantity demanded (becomes less affordable)

8 - What is supply?

* Quantity a producer is willing and able to supply at a given price


* An increase in price will result in an increase in supply (maximize profits)

8 - What is market equilibrium?

* Quantity supplied equals quantity demanded at a given price

8 - What is price?

The factor that will influence market and be causing a given supply or demand curve movement

8 - Healthcare spending is

unexpected, unplanned, and expensive

8 - What do risk pools do?

allow health insurance companies to charge premiums that reflect the average cost of everyone

8 - Who are healthcare premiums determined by?

Those that are in the risk pool

8 - What is asymmetric information?

when one party has more knowledge than the other, as when providers of care have much more information than patients.

8 - What is the definition of morbidity?

the state of being unhealthy for a particular disease or injury

8 - What is the definition of mortality?

the number of deaths that occur in a population

8 - What is QALY?

quality-adjusted life year

8 - What do QALYs do?

calculate the cost-effectiveness of medical treatment

8 - What is the definition of health?

**“a state of physical, mental and social well-being and not merely the absence of disease” [the WHO definition ] – definitions of “health,  health care, illness, diseases”**

8 - What is elasticity?

a change in demand in response to a price change

8 - What is a perfect market (competition) structure

* many buyers and sellers
* a homogeneous product (a uniform product),
* Freedom of entry and exit (no barriers), and
* perfect consumer information

8 - What is a monopoly?

a market with only one seller (energy)

8 - What is a monopolistic competition?

a market with many sellers, but there are barriers to enter and exit

8 - What is a oligopoly?

a market with a few sellers

8 - What is a duopoly?

a market with two sellers

8 - What is a monopsony?

a single buyer in a market

9 - What are the four different strategies/approaches to dealing with risk?

* Avoid
* Accept
* Reduce
* Transfer

9 - Why should we have health insurance?

* Protects against unexpected risk
* Provides essential health benefits in the event of sickness or injury
* Lowers the cost of healthcare
* Provides access to preventive care
* May compensate for loss of income if the sickness or injury makes the insured unable to work

9 - Who provides most of the health insurance in the US?

An employer as a benefit of employment

* Employers often give health insurance coverage to employees as a tax-deductible cost of doing business, and employees usually receive these benefits tax-free

9 - What is a managed care model?

directs patients to networks of providers and reviews and man-ages cost and use

9 - What is the MCO?

Managed Care Organization

9 - What does the MCO do?

generic term applied to all types of managed care plans

9 - What does HMO stand for?

health maintenance organization

9 - What does PPO stand for?

preferred provider organization

9 - What does POS stand for?

point-of-service plans

9 - What does EPO stand for?

exclusive provider organization

9 - What organization has the most restrictive rules pertaining to patients and providers?

the HMO (health maintenance organization)

9 - What organization has the most flexible plan?

the PPO (preferred provider organization)

9 - What are managed care plans designed to do?

* restrict enrollees’ ability to choose healthcare providers by establishing networks of preferred providers


* reduce costs


* improve quality

9 - What were the goals of the ACA

to make affordable health insurance available to more people instead of structural change in healthcare system

\
in addition it

* Offers consumers discounts (known as tax credits) on government-sponsored health insurance plans
* People receive discounts to help offset health insurance costs, their household income is between one and four times below the Federal Poverty level

9 - What is the ACA?

affordable care act

9 - What is a community rating?

A method of setting insurance premiums that uses the general community population (e.g., a metropolitan area) as the risk pool.  It makes the healthy subsidize the unhealthy.

9 - What is an experience rating?

A method of setting insurance premiums that clusters people into smaller risk pools determined by their health history, age, gender, and other factors to set premiums. (In contrast with Community Rating)

9 - What is the difference between community and experience ratings?

* **community rating = everyone pays the same rate, regardless of age, gender, or health status.**
* **experience rating = healthier populations gain an advantage and pay lower premiums using, but those with greater healthcare needs tend to pay more—sometimes much more.**

9 - What does MLR stand for?

medical loss ratio

9 - What does an MLR do?

determines how much an insurance company spends on healthcare services

9 - What is a deductible?

the (annual) fixed amount of healthcare expenses that must be paid before the insurance starts covering medical costs

9 - What is coinsurance?

requires individuals to pay a percentage of the cost for a healthcare service. The amount varies, but most insurance plans pay for about 80 percent of the costs, while the insured must pay the remaining 20 percent

9 - What is a copay?

a set, flat amounts that individuals pay for a healthcare service

9 - What does out-of-pocket refer to?

The amounts that individuals pay from their own resources, expenses that exceed the amount that insurance pays

9 - What is cost sharing?

the amount of money a member must pay out-of-pocket for each type of covered benefit. It applies only to benefits that are covered by the plan, not to services or goods for which no coverage is offered.

9 - What are the THREE basic types of cost sharing?

* copayment
* coinsurance
* deductible

9 - What is adverse selection?

when insurance customers choose coverage according to their individual health and needs. Individuals with a lot of healthcare needs will enroll in health plans with many benefits, while healthy people with limited healthcare needs might even choose not to have health insurance. When only the sick sign up for health insurance, the average cost of the risk pool can skyrocket, making health insurance unaffordable and causing even more people drop their insurance.

9 - What is moral hazard?

the tendency for people to increase their use of healthcare, regardless of whether doing so is necessary, because they have health insurance.

10 - What is one quality report specific to hospitals?

the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

10 - What does the HCAHPS do?

asks patients about their experiences and is used by hospitals to improve the healthcare experience

10 - What is the Iron Triangle?

* access
* cost
* quality

10 - What does the triple aim do?

focuses on improving the patient care experience, improving the health of populations, while simultaneously reducing the per capita cost of health.

10 - What is accreditation?

“a symbol of quality that reflects an organization’s commitment to meeting certain performance standards”

10 - What is the purpose of accreditation?

to help providers to improve healthcare quality and to signal to the public that they meet the standards and regulations of a recognized external body

10 - What is the largest accrediting organization in the US?

The Joint Commission (TJC)

10 - About what percentage of US hospitals does the TJC accredit?

88