HEALTHCARE ECONOMICS
HEALTH INSURANCE
the rising cost of healthcare good for the economy, but the expenses are a burden for most individuals and families
in the 1920’s, the US developed a system of health insurance to help cover the cost of medical expenses
the patient protection and affordable care act( ACA ) of 2010 was passed to reduc the number of uninsured in the US
HEALTH INSURANCE TERMS
premium- the amount paid to an insurance agency for a health insurance policy
deductible- the amount that must be paid by the patient before the insurance agency will begin to make payments
co-payment- an amount paid by the patient for a certian service
co insurance- the co insurance is the percentage of costs of a healthcare service that is paid by the patient after they have paid the deductible. For example, you have paid your deductible and have an $100 office visit witha. co insurance of 20%. you would be responsible for $20 and the health insurance agency would pay the rest ($80)
out of pocket expense- an out of pocket expense is a medical bill that must be paid by the patient. many health insurance policies have a limit to the amount of out of pocket expenses to be paid by the patient during a year
cost sharing reduction(CSR)- this discount applies to deductibles , copayment, and co insurance for premuim health plans. it lowers out of pocket expenses
premuim tax credit- based on your annual income and household info, this credit lowers your monthly insurance premium paymennt on qualified health plans
health insurance portability anf accountability ( HIPAA )- this law protects patient info and confidentiality. signed into law in 1996, HIPAA makes it illegal to gain access to a patient’s health info without their permission. it also places strict permissions on the transfer of personal health info ( PHI ) between organizations
HEALTHCARE FRAUD
healthcare fraud is a crime. examples include:
using someone else’s health info as if it was your own
billing for medical services that were not provided
delivery of unnecessary medical services
misenterpretation of medical services provided for higher reimbursment
providing or receiving money for participating in any of the above fraud schemes
HEALTH INSURANCE THEN AND NOW
the firest broad coverage was workers compensation in 1914 anc provided cash payments to injured workers with job related injuries or illnesses
today the affordable care act requires health insurance companies to cover 10 essential health benefits:
outpatient care
emergency services
hospitalizations
pregnancy, maternity and newborn care
mental health and substance abuse treatment
prescription drugs
rehabilitative and habilitative services and devices
labortory services
preventative health services
pediatrics services
INDIVIDUAL AND GROUP INSURANCE
individual insurance is when a person purchases a policy and agrees to pay the entire premium for health coverage
group insurance is generally purchased through an employer. the premium is split between the emplyer and the person being insured
INDEMNITY INSURANCE
in indemnity insurance, patients must pay for all healthcare expenses out of their own pockets. afterward, the insurance agency wll reimburse the patient for a percentage of the expenses
indemnity insurance does not work for everyone. many people cannot afford to pay for their medical expenses out of pocket
MANAGED CARE
two primary concepts of managed care:
to promote good health
to practice preventive medicine
managed care plans offer medical services through a system of providers offers services of healthcare providers. the system of providers offers services at reduced rates
TYPES OF HEALTH PLANS
MANAGED CARE
health maitenance organizations
preffered provider organizations
point of service
HEALTH MAITENANCE ORGANIZATIONS( HMOs )
clients must pay a premium, deductible, and co payments
clients must visit in network doctors and select a primary care physician
HMOs urge clients to practice healthy living and to recieve preventive treatments
PREFFERED PROVIDER ORGANIZATION ( PPO )
clients must pay a premium, deductible, and co payments
clients do not have to choose a primary care physician\clients may visit non network physicians, but coverage is greater with in network physicians
PPOs often have other fees and co payments
EXCLUSIVE PROVIDER ORGANIZATIONS ( EPOs )
coverage for healthcare services is limited to care from providers or hospitals in the plan’s network, except for emergencies
referral is not required to see a specialist
no coverage for care form out of network providers
POINT OF SERVICE ( POS )
clients must pay a premium
clients must choose a primary care physician
for in network physicians, there is usually no deductible and co payments are low
specialists may be non netowrk physicians, but coverage may be limited
MANAGED CARE COMPARISONS
HMOs, PPOs, EPOs, and POS plans have similarities and differences. it is important to know how these types of managed care compare with each other
MAKING INFORMED DECISIONS
the cost effective plan depends on an individual’s healthcare need and the coverage included in the plan
anyone who buys health insurance should research and compare the types of plans that are available
people who know in advance that they will need extensive healthcare should research prices for the expected care
GOVERNMENT PROGRAMS
PUBLIC HEALTH INSURANCE PROGRAMS
with public health insurance programs, the federal government finances healthcare services recieved by eligible groups of the population.
medicaid
medicare
military health system
tricare
veterans’ health administration
GOVERNMENT PROGRAMS
public medical assistance:
medicaid
medicare
affordable care act ( ACA )
expanded eligibility criterea for medicaid
provided financial assistance for those who do not qualify for medicaid or lack insurance from employer
MEDICAID
needs-based program
designed by the federal government, administered by the state governments
provides medical assistance to individuls and families who the state determines to be “medically needy”
MEDICAID SERVICES
services typically include:
hospital services
prenatal care
child vaccines
pediatric services
physician services
diagnostic testing and X-rays
rehabilitation ( rehab ) and physical therapy
prescription drugs
home healthcare
MEDICAID EXPANSION
the ACA provided the foundation for medicaid expansion. since it is a voluntary program and states may decide wether or not to participate, states also decide wether or not to expand medicaid for their residents
as pf may 2019, 37 states including washington dc, have elected to expand medicaid
MEDICARE
entitlement program for any citizen 65 or older
administered by the federal government
after deductible, medicare will cover 80% of all medical expenses
MEDICARE SERVICES
part a: hospital care
hospitalization
skilled nursing facilities
home healthcare
hospice care
long term care facilities
part b: outpatient services
medical expenses, including therapy, medical equipment, and testing
preventive care
HEALTHCARE FOR THE MILITARY
the us department of defense operates the military health system which provides medical services to active duty and retired military members of the armed forces and their families.
TRICARE is the health insurance program of the militray health system
the verterans health administration ( VHA ) is the largest integrated health services system in the united states