US Healthcare Exam I terms

access

availability of doctors and nurses for patients

affordability

can patients afford healthcare and the services provided?

appropriateness

are specialty doctors available to provide unique treatment?

Excess

over-insured: getting unnecessary treatments and procedures

deprivation

patients are underinsured: certain procedures or medications are not covered. to many out-of-pocket expenses

affordable care act (ACA)

requires employers with 50 or more full time employees to provide healthcare coverage. penalizes those that do not with fines (3340$ - the first 30 employees)

clinical care + standard of living + public health measures =

outcome on health of a population

health care system

healthcare providers, hospitals, and the insurance or programs that pay for them

out-of-pocket expenses

services paid for completely by the patient, not through insurance

private insurance

an insurance plan you pay for monthly to cover healthcare expenses.

employment based private insurance

insurance provided by your employer by taking a certain amount of money out of your paycheck

government financing

government created medicare and medicaid to help the elderly and the poor afford healthcare in 1965

Medicare

created in 1965 for the elderly through social security enrolled people automatically at age 65.

for those under 65 they need to be disabled and receiving social security for 24 months. individuals with ALS, end stage renal disease or transplants do not have to wait.

split into 4 parts

medicare part A

covers inpatient care, skilled nursing facility care, behavioral and mental healthcare, hospice care, and home health services. financed by social security

Medicare part B

provides coverage for medically necessary services, preventative services and is financed through income tax, federal tax, and premiums.

Medicare part C

includes more healthcare coverage and full prescription drugs coverage. also called medicare advantage plus. Medicare subsidized premiums with a majority of healthcare plans are health maintenance organizations (HMOS). funded by medicare, government, and premiums

medicare part D

prescription drug benefits (RX only). funded by the state and federal funds, premiums, copayments, and coinsurance

Medicaid

1965-2014: low income and fit into categories of eligibility

• children covered 100%

• fed gov paid 50-76% of total cost depending on income

2015: medicaid expansion lifts eligibility criteria, income 138% above fed poverty level

• fed gov paid 100% from 2014-2016 than decreased to 90%

individual mandate

legally required to have health insurance. use marketplace to purchase health insurance

community rating

all have the same premiums no matter the health status but difficult for insurance to be competitive

experience rating

base premium decided on average “needs” of the group

• higher premiums for coal workers, elderly, and sick

• is discriminatory

• began to be competitive

consolidated omnibus budget reconciliation act (COBRA)

a law that lets you temporarily keep your work sponsored health care for 18-36 months after losing a job or significant life change.

progressive payments

rising % of income taken as income increases

• more income→ the higher the payments

regressive payments

decreased % of income taken and income increases

• increased income → decreased payments

proportional payments

the ratio of payment to income is the same for all income classes

risk

the potential for providers and payers to lose money, earn less money, or spend more time without additional payment when delivering healthcare

3rd party payer

health insurance companies and the government

fee for service

price set by 3rd party payers and does not discourage providers from taking on sick providers

capitation

when doctors receive a fixed payment amount per patient regardless of what services that patient uses. increases the risk on the provider due to being a preset amount.

diagnostic related group (DRG)

care provided for documented diagnosis during hospital admission

global budget

a fixed payment made by 3rd party payer to cover all hospital services for all patients over one year (used in Canada and Europe)

preferred provider organization (PPO)

a form of a managed care plan. the insurance company agrees to contracts with a limited number of physicians and hospitals to care for patients.

• payments are less than fee for service

• company performs utilization review to authorize or deny services

• patients pay extra for services outside the preferred network

accountable care organizations (ACO)

payment model designed by 3rd party payers that combine fee for service and global budget payments

• providers provide coordinated care

• focus on quality of care

• puts physician offices and hospitals at risk

Primary tier

General practitioners provide physician service at the primary care level

Secondary tier

Physicians who specialize in areas of medicine such as cardiology. Typically located in hospitals, consultants for outpatient

Tertiary tier

Subspecialist such as cardiac surgeon or immunologists. Located usually in larger medical center.

value based payment

reward healthcare providers with incentive payments for the quality of care they provide. puts risk on the doctors and hospitals

regionalized model of health care

broken into three tiers that emphasize primary care.

• two types of hospitals; community and university

dispersed model of health care

less distinct between the 3 levels of care which allows patients to self-refer based on their needs and enables patients to receive care from a specialist of their choice whenever they want.

• three types of hospitals; university, community, and rural

patient centered medical home

physicians went to patient homes to provide care

pre-paid group practice

also known as HMOs. combine the financing and delivery of health care into one organization. patients pre pay each month for any health care they may need

vertical integration

the combination of several levels of corporate operations into one company. Ex. Kaiser hospitals and medical groups

virtual integration