Ch. 3 Intro to Health Professions

Health care in the United States funding

Health care in the United States funding

Through a variety of private payers and public programs

Public health care funding

Federal, State, and local governments

Private health care funding

Private health insurance

Privately funded health care

Out-of-pocket expenditures, philanthropy, and non-patient revenues (such as revenue from hospital gift shops and parking lots) as well as health services that are provided at employer's establishments, immediate care clinics, or clinics within pharmacies.

Public health spending attribution

The programs administered by the Centers for Medicare and Medicaid Services (CMS) Medicare, Medicaid, and the Children's Health Insurance Program (CHIP) and the Health Insurance Marketplace subsidies.

Sources of federal revenue

Income tax, payroll tax, excise (fuel, alcohol, tobacco), estate (assets inherited), and other taxes.

Payroll taxes funding

Social security, Medicare, Hospital Insurance, and unemployment insurance.

Traditional method of reimbursement

Fee-for-service - paying the provider at the time of service.

Fee-for-service

The provider - doctor, hospital, or clinic is financially rewarded for the volume of services performed.

Capitation

Paying the practitioner or hospital a fixed amount for a specific service.

Example of capitation for private health insurance

Health maintenance organizations

Health Maintenance Organizations (HMOs)

They limit consumer choice to health professionals and hospitals that contract with the HMO.

Long-term contracts with providers

Used by Medicare and Medicaid for a population or a group of patients.

Managed care organization (MCO)

A healthcare delivery system designed to manage cost, utilization, and quality.

Medicare Advantage Plans

A form of MCO; Medicare pays a fixed dollar amount per enrollee per month to the insurance company offering Medicare Advantage plans.

Shift away from fee-for-service

To improve quality while reducing costs.

Consequence of MCOs

MCOs require pre approval for surgery and other costly treatments.

Hospital Readmission Reduction Program (HRRP)

Where hospitals receive lower reimbursement rates for all patients on Medicare if hospital readmission occurs sooner than 30 days after discharge.

Bundled payments and accountable care organizations (ACOs)

Both are examples of capitation. Bundled payments are made for an episode of care: for example, hospital and homecare services.

Medicare program

A federal health program for people aged 65 years and older, certain disabled people younger than 65, and any adult with permanent kidney failure (end stage renal disease) or amyotrophic lateral sclerosis (ALS or Lou Gehrig's Disease).

Medicare benefits

Patients on Medicare are entitled to the same benefits and care as those with private insurance.

Medicaid program

The federal-state cooperative health insurance plan for those who are not eligible for health insurance through an employer and cannot afford to buy health insurance through the Marketplace.

Implementing Medicaid

The Centers for Medicare and Medicaid Services (CMS) within the Department of Health and Human Services (HHS) is responsible.

Medicaid eligibility

Low-income individuals: US citizens or legal immigrants, pregnant women, children, parents of low-income children, seniors, and those who have disabilities.

Medicaid as an entitlement

Based on two guarantees: 1. All Americans who meet Medicaid eligibility requirements are guaranteed coverage, and 2. States are guaranteed matching funds from the federal government.

Medicaid care model

The majority of Medicaid programs use a managed care model, while others use a fee-for-service model.

Medicaid beneficiaries care locations

Community clinics, public hospitals, and academic health centers.

Medicaid coverage in 2019

1 in 5 Americans were covered by Medicaid.

Medicaid funding

The largest source of funding for mental health, substance use disorders, maternal health, and long-term care services.

EPSCT

Early and Periodic screening, diagnostic, and treatment for infants, children, and adolescents under age 21 enrolled in Medicaid.

Dual-eligibles

Those enrolled in both Medicare and Medicaid.

Nursing home residents on Medicaid

Medicaid covers almost 2/3rd of nursing home residents.

Medicaid waivers

A policy that allows individual states to test new ways to deliver and pay for healthcare services for Medicaid and CHIP.

Children's Health Insurance Program (CHIP)

Provides federal matching funds to states to provide healthcare coverage to children in families with incomes too high to qualify for Medicaid.

CHIP eligibility

A child must be under 19 years of age, uninsured, a citizen or meet immigration requirements, a resident of the state, and eligible within the state's CHIP income range.

Marketplace subsidies implementation

As part of the ACA as a way for low- and middle-income adults under 65 years of age to purchase health insurance with financial assistance.

Marketplace health insurance purchasers

Individuals who work part-time or are self-employed are able to purchase affordable health insurance.

Types of subsidies for Marketplace enrollees

The premium tax credit and the cost-sharing subsidy.

Marketplace plans categories

Based on how the costs are split between the cost of the monthly premium and the amount paid for healthcare services.

Significant change in government healthcare financing

When Congress approved Medicare and Medicaid.

Start of private health insurance

With hospital coverage in the 1920s because of increased consumer demand and increased costs for hospitals.

Diagnostic related groups (DRGs)

A prospective payment bill under which hospitals are paid a set amount for each patient in any of the established disease categories.

Managed care organizations divisions

Divided into Health maintenance organizations (HMOs), preferred provider organizations (PPOs), and Exclusive Provider organizations (EPOs).

Managed care definition

A system in which employers and health insurers channel patients to the most cost-effective site of care.

PPOs

Cover care provided both inside and outside the plans provider network.

Majority of Americans health care system

Private health insurance.

EPOs

Similar to HMOs since services outside the network are not covered, but do not require the primary care provider to make referrals to specialists.

Americans health insurance acquisition

A group financed by their employer; 60% of adults ages 18-64 in the US had coverage through an employer.

Employer-based health insurance enrollment

The majority are enrolled in a PPO (44%), HMO (19%), or high-deductible health plan with a savings option.

High-deductible health plan

Requires individuals to pay a set amount of healthcare costs at the beginning of each calendar year before the health plan covers the costs.