Case Management, Healthcare Systems, and Economics (N475)

voluntary agencies

planned parenthood is an example of what kind of private organization?

voluntary agencies = specific diseases and organs, specific phases in life, and specific groups of people such as elderly

ex. American Heart Association (AHA)

public health

organized effort by society to protect, promote, and restore people's health

federal

department of education/agriculture and WIC are examples of __ level subsystems

federal subsystems sets national priorities, funds programs, and coordinates across states; ex. CDC

direct

local health departments are responsible for delivery of public health services to citizens

ex. vaccines, inspections, local outbreaks, etc.

four categories of health: community (health promotion, screenings), environmental, personal (schools, jail, clinics), and mental

accreditation

process meant to assess the quality of services and care of an organization = quality improvement

ex. Joint Commission, National Committee of Quality Assurance

medicare

federal entitlement program that provides healthcare to those 65 years or older, disabled people, or those that have end-stage renal disease

part A

which medicare part is this?

medicare part that is essentially hospital insurance

may still have to pay a deductible for health services; co-payments required after 60 days

part B

which medicare part is this?

medicare part that is purchased by a monthly fee that helps pay for out-of-pocket costs for physician services/outpatient services

minimum is $148/month………plus deductible and insurance

part C

which medicare part is this?

medicare advantage plans that is an optional "gap" coverage purchased by private insurance companies

vision, hearing, dental care, and other services

part D

which medicare part is this?

medicare part that helps to pay for prescription drugs

optional; additional monthly payment and yearly deductibles

still have to pay 100% of the costs when the costs reach the "coverage gap"

medicaid

federal and state program that provides source of financing health care for those with low-income or disabled

federal government sets baseline services, but state may add more

indemnity plan

which type of healthcare plan?

• "traditional" plan
• pays all cost of covered services
• individual can choose any provider and services + manage their own healthcare
• costs reimbursed on a fee schedule

became very expensive and is now not used; people started to take advantage of it

health maintenance organization (HMO)

which type of healthcare plan?

• has more comprehensive care
• enrollees do not choose who they go to
• preventative care is covered, but not speciality

aims to reduce costs by only providing the most necessary services

preferred provider organization (PPO)

which type of healthcare plan?

• negotiated with providers for services at a reduced rate
• offers more flexibility to see out-of-network providers, but at a greater cost
• more flexible than HMO

point of service (POS)

which type of healthcare plan?

• combines HMO and PPO
• if individual stays within network = no costs, if individual goes outside of network = they must pay for it themselves

high deductible health plan (HDHP)

which type of healthcare plan?

• employees have lower monthly costs/premium but a higher deductible when they do see a provider
• usually paired with HSA

retrospective

__ reimbursement is when a provider charges the patient's insurance company for their service and is dependent on the cost of things such as supplies, equipment, taxes, etc.

providers often inflate the costs to get more money

prospective

___ reimbursement is when the provider or hospital is reimbursed a predetermined set amount (no matter the services they provide)

this was created as an alternative to retrospective reimbursement to hopefully prevent providers from running unnecessary procedures/screenings

HOWEVER, this led to providers UNDERproviding for the patients

HSA and FSA

health savings account and flexible spending accounts

essentially, these accounts hold money that the employee determines to be spent during a year early in the year and is deducted from their paycheck ("pretax")