HSA3111-Test 2 modules 6-9

health insurance coverage

In this chapter the phenomenon called 'moral hazard' results directly from ___________________________.

Remember the examples of the young guy and the car or the building on fire and how similar types of issues happen in the healthcare industry.

deductible

A health insurance plan pays for medical care only after the insured has first paid $1,000 out of pocket on an annual basis. The $1,000 annual cost is called _______________________.

Protection against risk

In a general sense, what is the primary purpose of insurance?

(d) Insurance protects an individual from catastrophic loss due to major medical bills because their risk can be calculated based on individual behavior and lifestyle factors.

From our discussion in class and the "insurance function" slide with narration, we know that the primary purpose of insurance is to protect against risk. For discussion purposes risk refers to the possibility of a substantial financial loss from an event of which the probability of occurrence is relatively small. The example used in class might help you with this question about the four fundamental principles underlying the concept of insurance.

Think about the Baylor example where all the teachers paid in an equal amount and if an occurrence happened their hospital bills were covered by the amount of money the group put in the original insurance program. Also, remember in our example there was enough money left over after paying for the occurrence, along with the teachers' repetitive monthly payments that the insurance program could continue because it was financially sound.

Which response is not one of the four fundamental principles associated with the concept of insurance?

(a) Members of insured group share actual losses on some equitable basis.
(b) Insurance mechanism transfers risk from the individual to the group.
(c) Risk is unpredictable for the individual insured.
(d) Insurance protects an individual from catastrophic loss due to major medical bills because their risk can be calculated based on individual behavior and lifestyle factors.
(e)Risk can be predicted with a reasonable accuracy for a large group.

each time the insured receives health care services

A copayment is generally paid___________. Remember our example in class that each time an individual went to see a doctor they had to pay $10.

Prospective Payment System

What does "PPS" stand for?

d

Typically, tertiary care:

a) All of the above
b) Takes place outside of traditional healthcare facilities
c) Does not depend on technology
d) Is highly specialized

c

How is community-oriented primary care (COPC) different from primary care?

a) COPC adheres more strongly to the biomedical model.
b) All of the above
c) COPC adds a population-based approach to identifying and addressing community health problems.
d) COPC does not believe in the link between primary and secondary prevention.

Pain and symptom management

What is palliation?

b

Countries whose health systems are oriented more toward primary care achieve:

a) Higher expenditures in the overall delivery of care
b) Higher satisfaction with health services among their populations
c) None of the above
d) Worse health outcomes

unethical and illegal practices aimed at getting payouts from a government-funded healthcare program (e.g., Medicare)

The second BL video after moral hazard in Module 6 and the second BL video after outpatient services in module 7 were a series and focused mainly on the following-

upcoding

using a particular code for a procedure that is more complex and lengthy than the actual procedure performed to increase the reimbursement paid to the doctor

Providers have an incentive to deliver nonessential services

What is the incentive under fee-for-service reimbursement?

provide unnecessary services

Capitation removes the incentive to

Children under the age of 26

The ACA specifies that ______ can be covered under their parents' health insurance plans.

It makes providers cost conscious

In terms of MCOs what is the purpose of risk sharing with providers?

fixed monthly fee per member

Capitation is best described as

from the MCO to the provider

From chapter 9, under capitation the risk is shifted

deliver more services than what would be medically necessary because a greater volume would increase their revenues

Under the fee-for-service system, providers had the incentive to

Lack of choice of providers

What was the consumers' main gripe against managed care during the 1990s?

outpatient

ambulatory and outpatient are often used interchangeably, but _______________ is typically more comprehensive.

outpatient

_____________ services have been growing since the 1980s

tertiary care

Complex care, usually done at an institution-based facility (large teaching hospital), technology driven, specialized, i.e. trauma, burn treatment, open-heart surgery

point of entry (gatekeeper), coordination of care, essential care

3 elements-WHO definition of primary care

True

T or F: Every 13 minutes 100 people turn 60 every hour every day until 2024

florence nightingale

Founder of modern nursing

The Hill-Burton Act

Instigated after WWII: most community hospitals est. as a result of this act, provided funds for community hospital

relieve shortage of hospitals

The hill-burton act was passed to

Marie Curie

Woman who is known for her work in radiology and won nobel peace prize

Dame Cicely Saunders

Woman who founded palliative care

NCQA (National Committee for Quality Assurance)

MCOs are accredited by the

Decrease utilization

main purpose of cost sharing

Occurrence policies

gold standard, expensive, protect against any claims that occurred during the policy period no matter when it was made

claims-made policies

cover only those claims made or reported during the policy year

tail coverage

covers claims filed after expiration of claims-made policies

they are less expensive

Why do people get claims-made policies instead of occurrence policies?

occurrence monetary limits

1 patient brings a lawsuit due to an incidence

aggregate monetary limits

over a period of time, all of the aggregation of individual occurrences that may occur

torts

civil wrongs (1 individual suing another individual or company)

tort reforms

The following are types of what?
-Reducing the filing of claims
-limiting the plaintiff's award
-altering the plaintiff's burden of proof
-changing the judicial role

the statute of limitations (the amount of time from when a wrong occurs that you can bring a lawsuit)

you can reduce the filing of claims by reducing what?