ph162 quiz1

administrative costs

associated with the management of the financing, insur­ance, delivery, and payment functions of health care.  

balance billing

Medicare allows physicians to charge the patient the amount above the pro­gram's set fees and recoup the difference. In contrast, Medicaid prohibited this and, consequently, had limited par­ticipation from physicians  

managed care

an organized approach to delivering a comprehensive array of health care services to a group of enrolled members through efficient manage­ment of services needed by the members and negotiation of prices or payment arrangements with providers.

moral hazard

Consumer behavior that leads to higher utilization of health care services when the services are cov­ered by insurance

premium cost sharing

Employers rarely pay 100 % of the insur­ance premium; instead, most require their employees to pay a portion of the cost.

single payer system

a national health care program in which the financ­ing and insurance functions are taken over by the federal government

third party (ex, insurers)

Insurance often functions as the intermedi­ary among those who finance, deliver, and receive health care. The insurance interme­diary does not have an incentive to be the patient's advocate on either price or quality. At best, employees can air their dissatisfac­tions with the plan to their employer, which has the power to discontinue the current plan and choose another company. In real­ity, however, employers may be reluctant to change plans if the current plan offers lower premiums than a different plan.

national health system (nhs)

the government manages the infrastruc­ture for the delivery of medical care

socialized health insurance (shi)

government-mandated con­tributions from employers and employees finance health care. Private providers deliver health care services. Private, not­ for-profit insurance companies, called sickness funds, are responsible for col­lecting the contributions and paying physicians and hospitals

medical model

defines health as the absence of illness or disease

acute conditions

relatively severe, episodic (of short dura­tion), and often treatable and subject to recovery.

subacute conditions

less severe phase of an acute illness. It can be a post­ acute condition, requiring continuity of treatment after discharge from a hospi­tal.

chronic condition

persists over time and is not severe, but is generally irreversible. 

primary prevention

 refers to activities undertaken to reduce the probability that a disease will develop in the future 

secondary prevention

refers to early detection and treatment of disease. Health screenings and periodic health examinations are just two examples. Screening for hypertension, cancers, and diabetes, for example, has been instru­ mental in prescribing early treatment for these conditions.  

tertiary prevention

refers to inter­ventions that could prevent complica­tions from chronic conditions as well as further illness, injury, or disability. For example, regular turning of bed-bound patients prevents pressure sores, rehabili­tation therapies can prevent permanent disability

iatrogenic illnesses

illnesses or injuries caused by the process of healthcare

environment

risk factors encompass the physical, socioeconomic, sociopolitical, and sociocultural dimensions. 

lifestyle

behavioral risk factors

heredity

genetic risk factors

measures of physical health

morbidity and mortality

incidence

 the number of new cases occurring in the population at risk within a certain period of time, such as a month or a year 

prevalence

the total number of cases at a specific point in time in a defined population. is useful in quantifying the magnitude of illnesses of a relatively long duration.  

market justice

demand-side rationing (rationing by ability to pay)

social justice

supply-side rationing (planned rationing)

almshouse

also called a poorhouse, was the com­mon ancestor of both hospitals and nurs­ing homes. The poorhouse program was adopted from the Elizabethan system of public charity based on English Poor Laws.

pest-house

was operated by local governments (primarily in seaports) to quarantine peo­ ple who had contracted a contagious dis­ ease, such as cholera, smallpox, typhoid, or yellow fever. The main function was to isolate people with contagious diseases to prevent the spread of disease among the population.  

dispensary

established as outpa­tient clinics, independent of hospitals, to provide free care to those who could not afford to pay. Urban workers and their families often depended on such charity

mental asylum

were built by states for patients with untreatable, chronic mental illness. 

cultural authority

physicians gained this: the general accep­tance of and reliance on the judgment of the members of a profession because of their superior knowledge and expertise. 

organized medicine

development of hospitals as the center for the practice of scientific medicine and the professional­ization of medical practice became closely intertwined. 

gatekeeping

implies that patients do not visit specialists and are not admitted to a hospital without first being referred by their PCPs. 

voluntary health insurance

people chose to buy it themselves, unlike a system where the government requires everyone to have health insurance.

prepaid plans

contractual arrangement under which a provider must deliver all needed services to a group of members (or enroll­ees) in exchange for a fixed monthly fee paid in advance.

cost shifting/cross-subsidization

When hospitals or doctors provided free care to those who couldn't afford to pay, they would charge other paying patients more to cover the lost money

means testing

established by each state, but was expanded to include all age groups, not just the poor elderly 

medicare part a

the Hospital Insurance (HI) por­tion of Medicare, is a true entitlement program.

medicare part b

the supplementary medical insur­ance (SMI) portion of Medicare, is a voluntary program financed partly by gen­eral tax revenues and partly by required premium contributions.  

medicaid

An extension of the Kerr-Mills program of federal matching funds to the states, based on each state's financial needs

The HMO Act of 1973

was passed during the Nixon administration, with the objective of stimulating growth of HMOs by pro­viding federal funds for the establishment and expansion of new HMOs. The underlying reason for supporting the growth of HMOs was the belief that prepaid medical care, as an alternative to traditional fee-for-service practice, would stimulate competition among health plans, enhance efficiency, and control the rising health care expen­ditures. 

underwriting

a systematic technique for evaluating, selecting (or rejecting), clas­ sifying, and rating risks.

premium

the amount charged by the insurer to insure against specified risks

risk rating

Premiums are determined by the actuarial assessment of risk, that adjusts premiums to reflect health status.

deductible

the amount the insured must first pay each year before any benefits are payable by the plan.

copayment

flat amount that the insured must pay each time health services are received

group insurance

An insurance policy obtained through an entity, such as an employer, a union, or a professional organization, under the assumption that a substantial number of people in the group will participate in purchasing insurance through that entity.

managed care plans (mco)

PPOs and HMOs. saves money by combines different parts of healthcare like funding, insurance, care, and payments, which cuts out the middlemen and saves some money. Second, keeps costs down by sharing risks with healthcare providers or by getting discounts from them. This encourages providers to offer care more cost-effectively. Third, it saves money by organizing many different services for patients and checking if the services are needed and given in the cheapest way possible.

preferred provider plans (ppos)

Expensive, Provider preferences, Have more freedom, Open resources

cobra coverage

When people change jobs and move to a different employer, they may encounter a waiting period before their new health insurance starts. This waiting period is limited to 90 days or less under the ACA.

Medigap

private health insur­ance that can be purchased only by those enrolled in the original Medicare program-a program that has high out­ of-pocket costs 

medicare part c

medicare advantage, to get managed care plan like Kaiser or HMO

medicare part d

drugs (patch)

churning

A phenomenon in which people gain and lose health insurance periodically. 

CHIP

A joint federal-state program established as Title XXI of the Social Security Act under the 1997 Balanced Budget Act. it provides health insurance for children from low-income families who do not qualify for Medicaid. 

tricare (department of defense, DOD)

the health care program for uniformed service members, retir­ees, and their families around the world. it offers several differ­ent health insurance plans, including den­tal plans, and different options depending on whether the eligible beneficiaries live in the United States or overseas. For retirees age 65 and older, it offers a plan that works in conjunction with Medicare

veterans health administration (vha)

operates the largest integrated health ser­vices system in the United States.  

reasons for cost escalation

general inflation, third-party payment, imperfect market, growth of technology, increase in elderly population and chronic conditions, medical model of healthcare delivery, multipayer system and administrative costs, defensive medicine, waste and abuse, practice variation

top-down control (of total expenditures)

the country’s government establishes budgets for entire sectors of the healthcare delivery system. The government decides how much money can be spent on different parts of the healthcare system. They set budgets for the entire system and control how much is spent overall.

health planning

the government takes action to organize and allocate healthcare services and resources. This is done so that, according to government officials, everyone can achieve good health results.

price controls

changing how hospitals get paid for treating Medicare patients. Instead of getting paid after the fact for whatever the care cost (cost-plus), they started getting paid a set amount in advance based on the patient's diagnosis (prospective payment system), determined by categories called diagnosis-related groups (DRGs). This change happened because of new rules in the Social Security Amendments of 1983.

anti-trust regulation

prohibit business prac­tices that stifle competition among pro­viders. The purpose of is to ensure competitiveness and, in turn, the efficiency of economic markets. 

availability

The fit between service capacity and individuals' requirements

accessibility

 the fit between the locations of providers and patients

accommodation

the fit bet­ween how resources are organized to provide services and the individual's ability to use the arrangement. 

acceptability

 reflects the attitudes of patients and providers and refers to the compatibility between patients' atti­tudes toward providers' personal and practice characteristics and providers' attitudes toward their clients' characteristics and values.

equitable/inequitable access

distribution of health care services according to the patient's self-perceived need

realized access

type, size, and purpose of health services

health plan level

The contractual arrangement between a managed care organization and an enrollee, including the collective array of covered health ser­vices to which the enrollee is entitled. 

donabedian model

structure (resource inputs), process (actual delivery of health care), outcome (final results)

risk management

limiting risks against lawsuits or unexpected events