PHP 0310 FINAL TERMS

who definition of health

a complete state of physical, mental, and social well-being, and not merely the absence of disease or infirmity

health related quality of life

biological and physiological variables --> symptom status --> functional status --> general health perceptions --> overall quality of life

biological and physiological variables

molecular and genetic factors, functions, diagnoses, lab values, exam findings

______ drive care seeking and care costs

symptoms

whitehall study 1 (1967)

mortality is related to civil service grade

determinants of health

behaviors, social circumstances, environment, genetics, medical care, and stress_

___% of health is attributable to medical care

10

market justice

views health care as an economic good; assumes free-market conditions for health care delivery; implies an individual responsibility for health; rationing based on ability to pay

social justice

views health care as a social resources; requires active government involvement in health services delivery; implies a collective responsibility for health

markets don't work in healthcare because...

care is unpredictable, complicated, and expensive

tax subsidy for health insurance is ________ (progressive/regressive)

regressive (there are larger benefits to individuals in higher tax brackets with larger incomes)

why do we need insurance?

to protect against rare and unpredictable events, improve health, and reduce financial risk

what does health insurance accomplish?

access to care

oregon medicaid experiment

30k uninsured people randomly selected by lottery, and 10k given medicaid; led to an increased use of health care services, increased rates of diabetes detection and management, lowered rates of depression, reduced financial strain, and no significant improvements in measured physical health outcomes

premium

amount you pay to purchase insurance

deductible

the amount that an individual or family has to pay out of pocket each year before insurance takes effect

co-pay

a fixed amount that the insured person has to pay at the time a service is provided

co-insurance

a fraction of the cost of a service that the insured person has to pay

cost-sharing

refers to all the deductibles, co-pays, and co-insurances (costs incurred at the point of service)

asymmetric knowledge problem

you know more about your health than the provider; the provider knows more about medicine than you; the insurance company knows more about insurance than you

adverse selection

people who have higher health risks are more likely to buy insurance

risk pooling

the more people in a pool, the more accurately an insurer can predict health care utilization, and therefore cost

medical underwriting

the process of assessing risk

rate making

deciding what to charge people with different risks

___% of those under 65 in the us have a pre-existing medical condition

27

cream skimming/cherry picking

insurance companies' practice of trying to select and insure healthy people and avoid sick people

death spiral

giving healthy people the option not to buy insurance means that plans selected by sicker people (with more benefits) will eventually have higher and higher premiums

aca exchanges

state- or federally run websites to buy individual health insurance at subsidized costs

original aca insurance

< 138%: medicaid
138 - 400%: can buy insurance on the exchange with graduated tax credits and subsidies
> 400%: can buy insurance on the exchanges but no subsidies available

tax credits for the aca exchanges

given to people between 138 - 400%

cost sharing reduction subsidies on the aca exchange

given to people 138 - 250% fpl; ended by trump

bronze health plan

low premiums, high cost-sharing

platinum health plan

high premiums, low cost-sharing

american rescue plan act (2021)

increased tax credits, helped reduce premiums, and gave consumers access to affordable health care coverage

inflation reduction act (ira) (2022)

extended arpa subsidies for three more years; requires federal gov to negotiate prices for high cost drugs; requires drug cos to pay rebates if prices rise faster than inflation; eliminates coinsurance for catastrophic coverage; adds cap to out-of-pocket spending; limits cost sharing for insulin; expands part d lis eligibility

fee-for-service (ffs) reimbursement

provider gets paid a fixed, agreed upon amount for a service; used in medicare parts a and b; creates an incentive for volume, not quality; payer has all the financial risk; little incentive to control quality or cost

usual, customary, and reasonable rate (ucr)

payment method used until 1970s; physicians set ffs fees and patients and insurers paid them (still done in nyc today); replaced by rbrvs

resource-based relative value scale (rbrvs)

used by medicare and most private payers to set ffs prices; payment based on the relative value of the treatment, geographic region, and a conversion factor

capitation payment

payers (insurers) pay a fixed monthly amount to a group of providers per patient, and then the provider must pay for all of the patient's care for the month using this amount; financial risk lies on provider; concerns with stinting/underutilization

four functions of health care delivery

financing, insurance, delivery, and payment

managed care

an organized approach to delivering a comprehensive array of health care services through efficient management of services needed by members and negotiation of prices or payment arrangements with providers; set of tools used to control costs; tries to reduce utilization through preapprovals, utilization review, referral management, narrow provider networks, and careful use for formularies

narrow provider networks

a method to better control costs by limiting the number of providers the patient will receive insurance coverage for

prepaid group practice

a type of managed care (kaiser permanente) in which the insurer and provider are the same entity; patients have limited choice

independent practice associations (ipas)

a separate organization from the insurer that creates a provider network by contracting with solo and group practices; takes capitation money from the insurer

preferred provider organization (ppo)

a health plan in which the insurer negotiates a discounted ffs rate with "preferred providers"

medicare (1965)

health insurance for the aged and disabled; administered by cms in hhs; expanded federal authority to regulate health care providers; a federal entitlement program

categorical programs

benefit targeted at a category of person

entitlement programs

federal programs that are funded automatically; not dependent on annual appropriations

mandatory spending

spending authorized by legislation that is not subject to the annual congressional appropriation processes; entitlements

discretionary spending

spending that is subject to the annual congressional appropriation process

medicare eligibility

65+ and paid medicare payroll tax for 10+ years (if not, premiums); disabled; end-stage renal disease; alsk

medicare part a

hospital insurance program; covers inpatient hospital services, skilled nursing facility, home health, and hospice care; financed by a payroll tax that goes into a trust fund; covered by benefit periods (unlimited)

medicare part b

supplementary medical insurance program; covers physician, outpatient, home health and preventative services; financed by beneficiary premiums and general revenue; progressive premiums; ffs using rbrvs

medicare part c

medicare advantage; allows enrollment in private insurance plans

medicare part d

voluntary outpatient prescription drug benefit; through private plans contracting with medicare; can be stand-alone (pdp, 47%) or through medicare advantage (ma-pd, 53%); financed through general revenue, state payments, and premiums; must have a and b to join; requires monthly premium; includes catastrophic coverage

benefit period

a period that starts when a person is first admitted to a hospital and ends 60 days after discharge from a hospital or skilled nursing facility; used for medicare part a

prospective payment system (pps) (1983)

payment system for part a; hospitals are paid a fixed amount per admission according to the patient's principle diagnosis related group (drg) so hospitals are motivated to be more efficient and shorten stays

medicare access and chip reauthorization act (2015)

introduces merit based incentive payments and alternative payment models to move away from ffs

affordable care act (2010)

added new medicare-covered services; made significant cuts to medicare

dual eligibles

medicare beneficiaries who are also enrolled in medicaid; medicaid pays medicare premiums, deductibles, and copays; medicaid covers long term and custodial nursing home care

medigap

private insurance that covers costs that medicare doesn't cover; covers out of pocket payments

hmo act of 1973

established the term hmo; set criteria for federal qualification; provided capital to qualified hmos; recognized ipas as a type of hmo

___% of all medicare enrollees have medicare advantage

48

medicare advantage

medicare part c; private plans that contract with medicare to cover all part a and b costs, urgent and emergent care, and post-acute care; does not cover hospice (but will be covered by ffs); require part b premium; most plans have part d coverage; cost sharing with out of pocket limits

medicare advantage enrollment is _____ (increasing/decreasing)

increasing

true/false: patients in medicare advantage are less wealthy, non-white and healthier than those in ffs

true

low income subsidies (lis)

subsidies for low income beneficiaries to afford medicare part d

catastrophic coverage

after you reach your out-of-pocket limit, you will pay significantly lower copays and coinsurance for your drugs (5%) for the rest of the year; increasing because of higher drug costs and large price increases

true/false: administrative costs are lower for private insurance

false; they are substantially higher for private insurance than for medicare

medicaid

enacted in 1965; jointly funded by federal and state governments; covered up to 100% before aca; expanded up to 138% fpl under aca; eligib: low income pregnant women, children, and parents, children with special health care needs, low income adults with disabilities, low income elderly; no cost-sharing, but potentially premiums depending on state; most states use mco model to delivery services

federal medical assistance percentage (fmap)

intergovernmental revenue transfer of federal funds to the states; indicates the percentage of medical costs that are reimbursed by the federal government; increased by medicaid expansion (incentive to expand)

medicaid costs account for ___% of state spending

25

mandatory benefits

benefits that states must provide in order to receive federal matching funds

medicaid waivers

vehicles states can use to test new or existing ways to delivery and pay for health care services in medicaid and chip; must be budget neutral

____ of people aged 65+ will require nursing home care at some point

1/3

cms medicare-medicaid coordination office (mmco)

office established within cms to effectively integrate dual benefits and to improve coordination between cms and states

disproportionate share hospitals (dsh)

hospital with high medicaid/low-income patient volumes; receive federal payments from the government; states decide threshold of patient volume to receive funds; safety net hospitals; decline in payments expected in future

state children's health insurance program (chip)

enacted in 1997 to provide coverage for uninsured low-income children not eligible for medicaid; states receive enhanced match rate; pregnant women can be covered, and states can submit waivers to cover parents; cost-sharing optional for states (can't be more than 5% family income)

healthy kids act (hr 195)

provides federal funding for chip for 6 years; extends requirement for states to maintain coverage

arkansas waiver

enrollees must engage in 80 hours of work each month to receive care; many people have lost coverage; withdrawn by biden admin

block grants

pre-set amount of funding given to states to administer medicaid program; will have savings as long as total spending is less than expected; will shift costs to state governments

per capita cap

states receive a sum per enrollee; will shift costs to state governments

delivery

anything and everything related to the delivery of any type of medical care or service

number of hospitals and hospitalizations are ____ (increasing/decreasing)

decreasing

redeployment

hospital shift from inpatient care to outpatient

___% of practicing physicians are international medical graduates (img)

24

licensed practical nurse (lpn)

1 year of training

registered nurse (rn)

2 years training

advanced practice nurse

ma degree; mid-level practitioners

mid-level practitioners

nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, certified nurse midwives, physician assistants

doctor's new dilemma

whether or not to ask about patients' personal lives; wastes time but also avoids intimacy

primary care

provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community

integration (three c's of primary care)

comprehensive, coordinated, and continuous

secondary care

short-term, outpatient care with a potential technological focus

tertiary care

complex, institution-based, and highly specialized care (only major hospitals have it)

quaternary care

services that only a few doctors in the country can provide

quality-cost study

having more primary care providers is associated with higher quality and lower costs

simon paper

higher-value primary care practices have risk-stratified care management, careful selection of specialists, and coordination of care

current procedural terminology (cpt) codes

cpt codes determine how prices are set for ffs by cms; describe what you do (evaluation and management services and procedural services)

resource-based relative value scale update committee (ruc)

determines rbrvs; mostly run by specialists; determines rvus