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Late 1800's to the Early 1900's set the stage for health insurance due to the
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Allied Health Exam 2

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Late 1800's to the Early 1900's set the stage for health insurance due to the technology increases which increased efficiency in diagnosis and care, as well as more access to care, and increased cost of care.
Health Insurance began as a form of disability coverage that provided income during temporary disability due to bodily injury or illness
During WW1 anti german sentiment opposed a national health care plan.
During the great depression social service took center stage.
AMA & AHA opposed any plans to protect Physician wages
AMA & AHA 1948 largest and most expensive lobby campaign against national insurance
Workers’ Compensation 1910 - 1915 first broad-coverage health insurance in the U.S., originally designed to make cash payments to workers for wages lost because of job-related injuries and disease
private health insurance has prevented a national health care program
Group Hospital Plan and Birth of Blue Cross Justin Kimball began a hospital insurance plan for teachers at Baylor University Hospital in Dallas, Texas, capitated fee structure , became the model for Blue Cross plans around the country
The American Hospital Association (AHA) supported group hospital plans and coordinated them into a Blue Cross network
Blue Cross Network transformed insurance from a mechanism to reimburse for lost wages to one that reimbursed providers for the cost of medical care
Blue Cross was non profit and there were no shareholders.
Control of Blue Cross plans was transferred to an independent body forming Blue Cross Association.
In 1946 Blue Cross was in 43 states and serving 20 million people.
Blue Cross was the birth of commercial insurance.
Commercial insurance companies follow Blue Cross structure.
Private Insurance industry included hospital plans, and was AHA endorsed for ONLY hospital care.
From 1940-1950 hospital insurance rose from 9% to 57%
In 1939, the California Medical Association started the first Blue Shield plan
Fist blue shield plan was designed to pay physician fees.
Blue Shield plans were aimed at protecting the medical profession's own financial interests.
Blue Shield was AMA endorsed.
By 1974 Blue Cross and Blue Shield merged, today they are a joint corporation, and are in almost every state.
During World War II, employees accepted employer-paid health insurance to compensate for the loss of raises
Congress made employer-provided health coverage nontaxable, was equivalent to getting more salary without having to pay taxes
The US Supreme Court ruled that employee benefits were a legitimate part of union-management negotiations
By mid-1950’s commercial insurance companies offered health insurance.
Today – 850 health insurance companies contract with millions of employers to provide coverage.
Health insurance through the employer is the primary source of payment of healthcare services in the U.S.
Aspects in which managed care differs from conventional insurance are Collection of premiums assumption of risk, responsibility for delivery of services, making of payments to providers
Health Care Expenditures are money that is spent in the process of doing business
Health Care Expenditures include the cost of resources required to maintain a health care delivery system
Goal is to keep health care expenditures down.
Cost is related to the charge to the patients and insurance companies willingness to pay.
Expenditures occur in 4 major areas Financing,Technology and supplies,Facilities,Personnel
Financing source of money used to run a business
Increased health care spending can be caused by price increase in economy, life expectancy increases (more medical care needed), technology and research increases (increased cost).
Four main areas that account for health care spending include hospital care, physician and clinical care, prescription drugs, nursing and home healthcare. Other sources include specialty services, com minty/school spending, medical equipment.
Free-market Demand is determined by the process of goods and services on the one hand and people's ability to pay on the other
Heath Insurance desensitized both consumers and providers to the price of services.
Effects of financing and insurance include demand for services, covered services expand rapidly, growth of medical technology.
Negative effects of financing and insurance include moral hazard (ability to pay = more utilization), provider-induced demand (reimbursement= create demand)
Moral Hazard + provider-induced demand = increased health care expenditures and wasted resources.
Supply-side rationing restricting the availability of expensive medical technology and care (i.e. insurance will only pay for some procedures)
Demand-side rationing utilization of services curtailed due to lack of insurance; limited access to care
Today's complexity of financing is caused by many payers, many forms of payment, many programs and many reimbursement options.
PayPayers of healthcare include the patients (directly pay portion of the total cost of services) and the employers and government which are the primary financiers of health care.
Patients finance their own care and pay for those who can't afford it.
Many employers attach health care to wages, medicare tax is also deducted from pay as a prepayment for when 65.
General taxes subsidize health care for poor.
Cost-shifting and tax subsidies pay into catastrophic health for the uninsured.
Sources of financing health care include private insurance programs, public insurance programs, uncompensated or charity care.
Types of insurance include private (voluntary/personal) and public (government).
Private health insurance includes group insurance, self-insurance, individual private, and managed care organizations.
Public health insurance includes medicare and medicaid, and state children's health insurance.
Financing is any mechanism that gives people the ability to pay for health care services
In most cases, financing is necessary to have access to health care
Insurance method of payment for health care services
Insured person for whom the policy is for
Insurer (3rd party payer) employer or organization responsible for reimbursement of services
Provider individuals providing care or services
Benefits/coverage plan that employee chooses; contains the conditions and services under which payment is made
Premium cost (usually by monthly fee) that is paid by the insured for coverage
Policy legally binding contract of the insurance plan
Enrollment period time period when employees can take advantage of benefits
Deductible out of pocket expenses; dollar amount of services that must be paid by the patient or person responsible for the bill before the insurance will pay
Copay at time of service; patient pays for a portion of the services up front
Coordination of benefits clause that determines which insurance pays for services if insured has more than one
Out of pocket patient pays provider directly from own savings – no insurance involved
Fee for service insured purchases insurance to cover certain benefits; pay provider at time service is provided
Pre-payment insured pays fixed, predetermined amount for services rendered
Coding system of identification of diagnoses, procedures and services that were provided to the patient; describes the services
Billing charges posted to patient’s account for services rendered
Claims form sent to insurance company explaining charges incurred by the patient
Explanation of Benefits (EOB) a statement sent to the patient that explains which claims were paid and at what level
Risk the possibility of substantial financial loss from some event, where probability of occurrence is small
Insurance protects against risk
Insured (enrollee/beneficiary) an individual protected by insurance
Insurer an insurance agency that assumes the risk
Underwriting evaluates, selects/rejects, classifies, and rates risk
A insurance policy premium is based on shared risk.
Four principles of insurance risk include Risk is unpredictable for individuals, Risk can be predicted with some accuracy in a large group, Insurance can shift risk from the individual to the group by pooling resources, Losses are shared by all members
Restriction of usage reduce the overuse of services, often times through the use of primary care providers working as gatekeepers.
Limitation of access want to spread the risk
Major concern of risk management is how to effectively control rising health care costs.
Part of risk management is to reduce the number of people who require expensive car this is done through physicals, denial for preexisting conditions, some may accept those with preexisting conditions but not cover costs related to those conditions.
Due to risk management many people who are most in need of health insurance are not covered.
Cost Sharing Rationale is to control the utilization of health care services – if you pay, chances are you will be more responsible in utilization
Insurance requires some type of cost sharing.
The insured assumes at least part of the risk.
Cost sharing reduces the misuse of insurance benefits.
Findings of the Rand Health Insurance Experiment cost share lowers utilization without lowering quality
Three main type of cost sharing in private health insurance include premium cost sharing, deductibles, and copayments.
Premium cost sharing both parties pay premium.
Deductibles payment before insurance pays
Copayments out of pocket expenses patient contributes to care.
Coinsurance percent of bill insurance pays after deductible.
Stop loss provision Limits total out-of-pocket costs to a certain amount in a given year, once reached insurance pays 100%, protects against catastrophic illness or injury
Lifetime cap may be part of insurance limits total expenses paid by insurance company, seen with long term or chronic conditions ACA 2010 prohibits lifetime limits on plans sold or purchased after Sept. 23 2010
Third-party payers insurance companies, managed care organizations, BlueCross BlueShield, government
Reimbursement payment made by third-party payers to the providers of services
Types of reimbursements include Fee for Service, Package Pricing, resource–based Relative Value Scale, reimbursement under Managed Care
Fee-for-service Charges set by providers, each service is billed separately, UCR became common, usual customary and reasonable, main drawback is providers induce demand, payment to provider from insurance or out of pocket.
Package pricing (bundled pricing) number of related services in one price, reduce provider induced demand because fees are inclusive of all bundle services.
Resource Based Relative Value Scale (RBRVS) Under the omnibus budget reconciliation act of 1989, medicare developed the program to reimburse physicians according to "relative value" assigned to each service, based on time skill, intensity to provide service.
Discounted fees used by PPOs
Capitation Used by HMO's, per member per month fee to cover all needed services, prudent delivery of services, minimize provider-induced demand.
Retrospective reimbursement rates of reimbursement set after evaluating the costs. Based on costs that were directly related to the length of stay. Providers has no incentive to control cost.
Prospective reimbursement uses pre-established criteria to determine in advance the amount of reimbursement.
Four main prospective reimbursement methods are Diagnosis related groups (DRG), ambulatory payment classifications (APC), resources utilization groups (RUG), home heath resources group (HHRG)
Diagnosis Related Groups (DRGs) Established in 1983, for acute hospital inpatients, prospectively set bundled price, hospital earns a profit by keeping costs below the DRG reimbursement.
Ambulatory Payment Classification (APC) Implemented August 2000, medicare's outpatient prospective payment system (OPPS) for services provided by hospital outpatient departments. Bundled rate, reimbursement rates are associated with each APC group.
Resource Utilization Group (RUG) Medicare payments reimburse skilled nursing facilities, case mix, overall acuity level in a facility, evaluate patient's medical and nursing care needs, case mix determines a fixed per-diem amount, higher the case mix score, higher the reimbursement.
Home Health resource Groups (HHRG) A fixed, pre-determined rate for each 60-day episode of care, regardless of services given. OASIS, outcomes and assessment information set used to rate a patient's functional status and clinical severity. Assessment measures translate into points.
Patient Protection and Affordable Care Act (ACA) 2010 Most significant regulatroy renovation of US health care system since Medicare and Medicaid in 1965. Goal to decrease number of uninsured Americans, provide accessible health care to everyone by 2014, streamline delivery and reduce costs.
Two functions of financing are purchasing of health insurance and payment of services
Sources of financing health care are private insurance programs, public insurance programs, and uncompensated or charity care.
When ACA is fully implemented in 2014, burden of HC spending will shift to taxpayers.
Most popular form of financing health care is through private insurance, which is mostly employer based.
Private or voluntary/personal insurance types include individual private, group insurance, and self insurance.
High deductible health plans can also be group or self-insurance
Managed Care organization can also be individual as well as group or self-insurance.
Public or government insurance types include medicare and medicaid, state children's health insurance.
Private insurance is voluntary insurance meaning that it is not mandatory.
Private insurance is available in single or family plans.
Most private insurance is employer based.
There are many different types of private insurance providers such as Commercial, blue cross blue shield, managed care organizations, HDHP.
Individual private insurance is where the individual pays directly to the insurance company.
Those covered by individual private health insurance can pick options of coverage based on needs.
Those with individual private health insurance may include early retirees, and self-employed individuals.
In individual private health insurance risk is individually determined.
Within individual private health insurance premiums are determined by coverage picked.
Within individual private health insurance high risk people are often unable to receive coverage.
Group insurance is offered through an employer, union, or professional organization.
Group insurance anticipates large numbers of people in a group and will buy insurance through a sponsor (employer)
Within group insurance cost and risk are distributed equally among the insured.
Group insurance typically includes major medical and comprehensive coverage.
Self Insurance is where the employer covers itself.
Self-insurance occurs when large employer's work forces are large and diversified enough.
Those with self-insurance can predict their own medical experience.
Those with self-insurance can assume risk and pay all claims incurred by employees.
Within self-insurance high losses are covered through reinsurance which is purchased insurance from a private company.
Consumer Driven Health Plans (CDHP) feature high deductibles or upfront costs in exchange for low premiums, and different ways of paying.
Consumer Driven Health Plans gives consumers greater control and responsibility over how to use their health care money, features tax free dollars, and hospital coverage for catastrophic.
High Deductible Plans (HDHPs) Pay less for health care but still covered for catastrophic illness.
HDHPs feature low premiums but higher deductibles, as well as no copays for MDs.
Within HDHPs preventative care is typically not covered.
Within HDHPs yearly cap is based on out of pocket expenses.
The two main types of high deductible health plans or HDHPs are HSA or health savings account and HRA health reimbursement arrangement.
In a HDHP/HSA (health savings account) a high deductible health plan is combined with a health savings account, mainly the employee contributes to saving account on a tax-deductible bases, money in account is used to pay for health services until the high deductible is reached.
In a HDHP/HSA there is a cap on out of pocket expenses and employers may contribute, the funds belong to holder of account and accumulate without limit, unused money roll into the next year.
Within a HDHP/HSA there is a tax advantage because the account is tax exempt.
A HDHP/HRA is a health reimbursement arrangement it is a employer funded account that is tax exempt payments made for qualified medical expenses.
Within a HDHP/HRA employees pay medical expenses, premiums, and LTC insurance and then the employee is reimbursed by the company, unused funds can be carried over to the next year.
A HDHP/FSA is a flexible spending account it is similar to an HSA but there is a pre-tax on money in account for medical expenses, account can be used in conjunction with any health care plan, money left in the account expires at the end of the year, there is no carry over.
Managed Care Organization is a type of private insurance.
The three critical factors in differentiating between the types of MCOs are choice of providers, different ways of arranging services, and payment and risk sharing.
The most critical factor in differentiating between the types of MCOs is the choice of providers.
Types of managed care organizations include health maintenance organization HMO, preferred provider organization PPO, exclusive provider organization EPO, and point of service organization POS.
Health Maintenance Organizations or HMOs feature low premiums but less options, are copay driven rather than deductible, part of your premium goes to medical group whether you use or not, capitation is the primary method of reimbursement, increase in fee for service.
Health Maintenance Organizations are restrictive meaning in network providers and services are covered only.
HMO's are referral based meaning they are coordinated by an HMO provider or gatekeeper, who make all the decisions.
HMO's focus on wellness care feature preventive and screening services, "health maintenance" within the organization.
HMO models include staff model, group model, network model and independent practice association or IPA model.
HMO staff model features fixed salaried MD on staff in a large HMO.
A HMO staff model operates clinics and sometimes hospitals, that service only those enrolled in HMO.
Staff model MD covers all specialities in order to deliver care.
HMO staff model features more control over practice and MDs.
In an HMO staff model it is easier to monitor utilization.
In an HMO staff model you need a large number of enrollees to cover costs.
Enrollees in an HMO staff model are limited on the MDs they can go to.
HMO Group model contracts with a multi-specialty group practice.
In a HMO group model MDs are not employed by the HMO but by a group practice.
In an HMO group model they contract separately with one or more hospitals for specialty services.
In an HMO group model while not exclusive services, HMO has some control over utilization.
In an HMO group model the HMO pays group practice to provide services.
Independent practices can also treat non-HMO patients
HMO may own group practice as a separate corporation but one that is administratively tied to the HMO-service exclusive to HMO members.
HMO network model contracts with more than one medical group.
HMO network model is suited for operations in large metropolitan areas and across widespread geographic regions where group practices are located.
In an HMO network model the patient chooses which provider.
In an HMO network model the group practice is paid by capitation.
In an HMO network model the group practice is responsible for providing all MD services.
In an HMO network model doctors can make referrals to specialists but responsible for reimbursing them for the referrals not the HMO.
In an HMO network model there is low utilization control since no central overseeing agency.
An independent practice association or an IPA is an intermediary between an HMO and providers.
An IPA is a risk bearing entity.
The IPA is paid a capitation fee by the HMO.
In an IPA the HMO contracts to the IPA instead of directly with MDs
An IPA establishes contracts with both independent solo pracitioners and group practices with large numbers.
IPAs are independently established by MD groups.
In an IPA HMOs may create and invite area MDs to participate
An IPA is hospital based and structured so that only certain practices may participate.
IPA assumes the responsibility for utilization management and quality assessment.
In an IPA MDs are responsible for providing services but logistics of arranging MD services are shifted to the IPA.
Preferred Provider Organization or PPO is the most flexible.
In a PPO enrollees have more control over care decisions and are rewarded with lower deductibles and co pays if in network, typically higher copay for out of network.
A PPO is not referral based, patients manage and negotiate contracts with preferred providers in and out of network, more treatment options and no PCP.
A PPO is more flexible but the premium is higher to pay for this option.
In a PPO group practice is paid by discounted fees.
In a PPO there is a deductible driven plan that is paid annually.
In a PPO patients can use out of network providers, but there is a higher out of pocket cost to the enrollee.
In a PPO there is no gatekeeping within the network, you can see specialist without referral or prior approval, leads to little control over utilization.
A PPO guarantees volume of business to hospitals and MDs who in return accept reduced fees.
In a PPO MDs have no personal risk and get fee for service at an agreed upon reduced rate.
In a PPO a hospital is insured a patient population.
A POS a point of service organization is a combination of a HMO and PPO.
A POS is more flexible with in and out of network benefits, choose at time of medical service who to seek care from, allows the enrollees to seek out of network care at a higher out of pocket cost.
In a POS providers paid by capitation.
In a POS gatekeepers may be used to control utilization.
In a POS it is referral based, pick your primary care practitioner and specialty care with referrals for out of network providers.
A POS is a copay driven model.
COBRA Consolidated Omnibus Budget Reconciliation Act of 1985
COBRA is aimed to reduce gaps in coverage for individuals between jobs and their family.
Due to COBRA employer must extend benefits to former employees for 18 months.
COBRA may be extended to spouse or dependent up to 36 months.
In COBRA you must pay entire premium but it is still cheaper than purchasing on own.
Private insurance is any form of insurance NOT subsidized by the government, includes individual and employer-based.
Many types of health care plans available but they are usually employer driven.
Premiums, deductibles and co-pays vary.
Public insurance is government financed.
Accounts for 45.4 percent of total US health care expenditures public health insurance
Piecemeal was the addition of new programs and adds to the taxpayer's burden.
In 2010 31 percent are covered by public insurance.
Public financing supports categorical programs, not public in the sense that it can be used for uninsured or all people.
Categorical programs are each designed to benefit a certain category of people who meet the eligibility criteria to become beneficiaries.
Medicare and medicaid are categorical programs and were created under the social security amendments of 1965.
Before 1965, private health insurance was the only widely available source of payment for health care.
Before 1965 private health insurance was available primarily to middle-class working people and their families, the elderly, poor, and unemployed relied on their own resources.
Early debates on health reform occurred in the 1950s but americans did not want government overseeing health care.
Americans wanted reform initiative for the underprivileged whose health status was typically worse, and could not afford increasing health care costs also medical needs were usually more critical.
In 1957 a health care bill was introduced in Congress early debates on to include hospital and nursing home care for elderly however AMA opposed because it was a threat to the MD patient relationship, there was public debates that supported this bill resulted in compromise reform.
1960 Medical Assistance Act also known as the Kerr-Mills Act President Kennedy revived the effort to enact hospital insurance for the aged, congress responded with the Kerr-Mills Act. Act involved federal grants given to states so they could extend health services under welfare.
The Kerr-Mills Act was a failure to implement, it was deemed ineffective.
1964 President Lyndon Johnson made public health insurance a top priority.
AMA urged congress to expand Kerr-Mills Act.
Wilbur Mills proposed and Congress enacted 3 expansion initiatives Medicare Part A which included hospital and nursing home, medicare part B MD premium based and medicaid which made poor eligible.
Medicare is title 18 of the social security act.
Medicaid is title 19 of the social seurity act.
Medicare and Medicaid were instrumental in covering select populations.
Medicare and medicaid are financed by the government but delivered by private providers.
Medicare and medicaid put a huge burden on gross domestic product.
Medicare is title 18 of the social security amendment of 1965 it finances medical care for 3 categories of people, people 65 years or older, disabled of any age who are entitled to benefits for at least 24 months, people of any age with end-stage renal disease, and Lou Gehrig's disease.
Centers for Medicare and Medicaid Services (CMS) Agency under the US department of health and human services that administers the program. Enrollees expected to grow.
Medicare does not cover everything.
Medigap policies cover medicare deductibles and co-payments, may pay for services not covered by medicare.
Medicare Part A Hospital insurance HI
Medicare Part B Physician insurance/ Supplementary insurance SI
Medicare Part C Medicare advantage
Medicare Part D Prescription drug coverage.
Medicare part A is paid by social security tax and covers inpatient services, short term convalescence and rehab in a skilled nursing facility, home health, hospice, managed care, and administrative costs.
Medicare does not require a primary care MD
Medicare can see any doctor, hospital, other providers and facilities but must be medicare approved.
Medicare covers most medications.
Those with medicare may also have other coverage through employer, union, etc.
Those with medicare pay deductible, and coinsurance, out of pocket.
In medicare the timing of benefits is determined by a benefit period.
Benefit period begins on the day a beneficiary is hospitalized.
Benefit period ends when the beneficiary has not been in a hospital or a skilled nursing facility for 60 consecutive days, after a new benefit period begins.
A beneficiary can have unlimited benefit periods.
Medicare acute care hospital benefits include all expenses paid for the 1st 60 days after deductible met, deductible applies for each benefit period, copayment required from 61-90 days, max benefit period is 90 days, higher copay applies after 90 days. After 90 days lifetime reserve of 60 days.
Medicare acute hospital benefits include all expenses paid for first 60 days after deductible met, deductible applies for each benefit period.
Medicare acute hospital care requires a copayment from 61-90 days, max benefit period is 90 days.
For medicare acute care hospital benefits have a max benefit period of 90 days.
Acute care hopsital benefits includes a higher copay after 90 days.
Acute care hospital benefits include a lifetime reserve of 60 days after 90 days.
Medicare acute care hospital benefits include psychiatric services of 190 days lifetime.
Medicare acute care hospital benefits include private funds, medigap insurance and medicaid kicks in after medicare is exceeded.
Medicare certified SNF benefits eligibility begins after 3 consecutive days of hospital stays.
Medicare certified SNF benefits have a 100 days maximum.
Medicare admission to SNF must be within 30 days of discharge from hospital and related to hospitilization.
Medicare SNF benefits include 100 percent of payment for the first 20 days, then a copay from days 21-100.
Medicare home health benefits require the patient to be homebound and require intermittent or part-time skilled nursing care or rehabilitation care.
Medicare home health benefits cover up to 100 home visits after hospitalization.
Medicare home health benefits cover durable medical equipment at 80 percent.
In order for those under medicare to receive the hospice benefit the patient must be terminally ill.
Medicare hospice only need a token copayment required for prescriptions.
Medicare Part B contains physician insurance/supplementary medical insurance SMI
Medicare is financed partially by general taxes and premium contributions.
You are automatically enrolled in medicare but you can opt out.
Medicare is voluntary enrollees pay monthly premiums that are income based.
Medicare covers physician services hospital outpatient services (surgery) diagnostic tests radiology emergency department rehab ambulance dialysis radiation medical equipment and supplies Some preventive services
Medicare Part C is the Medicare Advantage which was formerly the medicare + choice 1998.
Medicare Advantage 1998 was part of the Balanced Budget Act of 1997.
Medicare advantage does not specifically include additional medical benefits, additional benefits may be offered by the private plans.
Medicare Part C is an alternative to enrollment in Part A, B, and D
Medicare Part C eliminates the need for medigap insurance.
In order to enroll in Medicare part C you must be enrolled in medicare.
Medicare contracts with private MCO, which must follow Medicare rules.
Private MCO's that contract with Medicare must have captivated fee structure from Medicare, premiums that are set by MCO, may have copays deductibles and a gatekeeper depending on the plan, HMO, PPO, fee for service, etc.
Private MDs must also agree to the terms of Medicare and can refuse to accept the plan coverage and fee terms.
Medicare Part C provids all of Part A and B coverage, some offer prescription coverage.
Medicare Part D Prescription Drug Coverage 2006
Medicare Part D was created under the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003
Medicare Part D is available to enrollees in Part A and B, but you must apply.
Medicare Part D offers 2 plans, Stand alone prescription drug plans (PDPs) – for those in Part A & B and Medicare Advantage Prescription drug plans (MA-PD) – part C beneficiaries
Medicare Part D is voluntary, requires a monthly premium, an annual deductible applies 320 dollars, payment is based on drug cost.
Medicare Parts A and B does not have comprehensive coverage, no vision, eyeglasses, dental, hearing aids, or routine exams.
Medicare Part B does cover pap smears, glaucoma screenings, cholesterol and prostate screenings, and pneumonia vaccines.
Medicaid is title 19 of the social security amendment of 1965
Medicaid is state financed health care for indigent, low income elderly, children under 21 in low income families, adults with dependent children from low income homes, the disabled and the blind.
Medicaid is jointly financed by the state and federal govt.
When financing medicaid the government matches federal funds according to the states per capita income, more income equals less funding, federal matching funds are dependent on services.
Means Tested Program for Medicaid Each state establishes its own eligibility criteria according to income and assets, covered services and payments to providers vary considerably from state to state.
Medicaid Disabilities everyone is eligible, automatically eligible if getting social security income benefits, some states it is by income.
Enrollees are also able to buy in to Medicaid disabilities if you are disabled with income above regular medicaid limits.
ACA 2014 will cover people under 65 including disabilities through medicaid if income is 15,000.
Medicaid covers Laboratory and X-ray Inpatient & Outpatient, Clinic, Nursing home, home care services Dental, vision for children Family planning LTC Medical and surgical dental for adults Other benefits by state
Accountable Care Organization ACO
Affordable Care Act of 2010 Authorized the Centers for Medicare and Medicaid Services to provide integrated delivery system for medicare patients, develop reimbursement methods, and offered incentives to reduce costs and improve quality, still in developmental phase.
State Children's Health Insurance Plan CHIP Created in 1997 under title 21 of the social security act to reduce the number of uninsured children in low income families.
CHIP was reauthorized through March 2009, in February 2009, the children's health insurance program reauthorization act of 2009 was approved by congress and signed by President Obama
CHIP in most states is available to families with income up to 200 percent of the poverty level 45,000 and if not covered under private insurance.
CHIP is a low cost insurance for children in families who earn too much to qualify for medicaid but cant afford individual personal insurance.
Federal Government matches state funds if they expand medicaid eligibility to enroll children under 19 years of age who do not qualify for medicaid coverage.
States can use existing Medicaid, create a separate CHIP program, or use a combined approach.
CHIP covers routine checkups, immunizations, dental and vision care, inpatient and outpatient services, laboratory and xray services.
COBRA is the Consolidated Omnibus Budget Reconciliation Act of 1985
COBRA reduces gaps in coverage for individuals between jobs.
In COBRA employer must extend benefits to former employees for 18 months.
COBRA may be extended to spouse or dependent up to 36 months.
COBRA requires you to pay entire premium but is still cheaper than purchasing own insurance.
Public insurance is designed to benefit a certain category of people who meet eligibility criteria to become beneficiries.
Public insurance includes Medicare, medicaid, CHIP, COBRA, and ACO
Iron triangle consists of cost, quality and access, an interactive relationship exists between the cost of health care, the quality of service delivered and people's ability to get health care when needed.
Past attempts at universal health care access have failed because increasing access means more expenditures based on the premise that cost and access go hand in hand.
Macro perspective is national.
National Health Expenditure NHE compares medical inflation to general inflation, measured by annual changes in the consumer price index, also compares changes in the national health spending to changes in the gross domestic product.
Micro perspective consists of providers and individuals.
Micro perspective involves employers who purchase insurance, providers who deliver services, consumers of health care.
Macro perspective or national cost is expected to rise due to the ACA.
The united states has a very high amount of health care expenditures as a percentage of gross domestic product.
Highest amount of health care expenditures is spent on private insurance.
Rising health care expenditures have been attributed to third party payment, imperfect market, growth of technology, increase in the elderly population, medical model of health care delivery, multi payer system and administrative costs, defensive medicine, waste and abuse and practice variations.
Third party payment leads to moral hazards, and provider induced demand.
In an imperfect market utilization of health care is driven by demand.
In an imperfect market quantity of health care produced and delivered is usually higher than in competitive markets.
In an imperfect market prices are permanently higher than the true cost of production.
Growth and intensive use of technology have a direct impact on the escalation of health care cost.
Technology leads to a higher cost of health care because it is expensive to develop, once developed creates new demand for use, technology also raise the expectations of consumers about what medical science can do to diagnose, treat disease and prolong life.
Increase in elderly population leads to higher health care costs because the elderly consume more health care at 3.5 times the rate of other age groups.
With increased life expectancy and the aging of the baby-boomer generation there are increases in elderly population which drives up cost.
Elderly drive up health care costs because chronic conditions necessitate care.
High cost is due to the medical model of health care delivery which emphasizes medical intervention while, de emphasizing medical prevention.
High cost is due to the medical model of health care delivery because health promotion and disease prevention have not accorded their place in the US health care delivery system.
Administrative costs are costs associated with the management of the financing, insurance, delivery and payment functions and can include managing enrollment, monitoring utilization, claims processing, denials and appeals, and marketing and promotion.
Administrative costs can amount to about 24-25% of all health expenditures.
Defensive medicine which drives up health care cost results because the US has many legal risks for providers, this leads to tests and service that are not medically justified, but are performed by physicians to protect against malpractice lawsuits.
Unrestricted malpractice claims add to health care costs.
High cost in the health care system is also due to wast and abuse which involves fraud.
Fraud is a knowing disregard of the truth and typically occurs when billing claims or cost reports are intentionally falsified.
Fraud is a major problem in medicare and medicaid.
Practice variations are referred to as small area variations.
Practice variations are the differences in practice patterns and have been associated with geographic areas of the country.
Practice variations signal gross inefficiencies in the US delivery system.
Practice variations increase health care costs without better outcomes.
Cost control efforts in the US have not been successful.
Implementing a system wide cost control initiative has not been feasible in a fragmented system.
Cost control efforts in the US have also been unsuccessful due to cost shifting where providers make up for lost revenues by increasing utilization or charge higher prices in other areas free of control.
The strengths of the US health care system also contribute to its weaknesses.
The US has the latest technology and well trained specialists which leads to the most expensive means of providing health care in the world.
Two major policy initiatives enacted by the federal government to contain costs have targeted hospitals with PPS and physicians services with resource based relative value scales.
Cost containment measures include health planning, price controls, peer review, and competitive approaches.
Health planning was an undertaking by the government to align and distribute health care resources that would achieve health outcomes for all, supply side rationing.
Health planning does not fit well in the US due to the market system, in the US market forces are allowed to govern the system.
Price controls are one of the most important undertakings to control price for inpatient hospital care.
Price controls included the conversion of hospital Medicare reimbursement from a retrospective to a prospective system which was based on diagnosis related groups as authorized under the social security amendments of 1983, caused costs to shift from inpatient to outpatient.
Peer review is the process of medical review of utilization and quality control and is carried out by or under the supervision of physicians who are paid by the US govt. to review Medicare.
PRO was a new system of peer review organizations established in 1984 to determine whether care was reasonable, necessary, of quality and provided in an appropriate setting, can deny payment if care does not meet with their standards.
PROs are also referred to as quality improvement organizations.
Competition is rivalry among sellers for customers can be in the form of technical quality, amenities, access or other factors
Competition in health care delivery means that providers of health care services try to attract patients who have the ability to choose from several different providers.
Demand side incentives are cost-sharing mechanisms that place a larger cost burden on consumers, encouraging consumers to be more cost conscious in selecting the insurance plan that best serves their needs.
Supply side regulations are antitrust laws in the United States, which prohibit business practices that stifle competition among providers such as price fixing, price discrimination and mergers.
Supply side regulations forces health care organizations to be cost efficient.
Quality is defined as The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge
The institute of Medicine in their evaluation of quality leave out the roles of cost and access
The institute of medicines definition of quality has implications that quality occurs on a continuum, unacceptable to excellent, that the focus is on services provided by the system not the individual behaviors, that quality may be evaluated from the individual or populations perspective, emphasis on desired health outcomes
According to the institute of medicines implication of quality professional consensus is used to develop measures of quality.
Quality indicators can be both micro perspectives, and macro perspectives.
Micro perspectives of quality focus on services at the point of delivery such as medical errors, patient care outcomes, and individual or organizations.
Macro perspectives of quality look at quality from the population's standpoint such as cost and access, reflect the performance of the entire health care delivery system.
US spends more of its national income on health care.
US has tremendous advances in technology.
US trails far behind in health status, spend more but do not produce better health, more does not equal better quality.
Donabedian in 1980 proposed three domains in which health care quality should be examined which are structure, process, and outcomes. All are important in measuring quality and are complementary and should be used collectively.
Structure includes facilities, resources, and staffing.
Structure can be defined as The relatively stable characteristics of the providers of care, of the tools and resources they have at their disposal, and of the physical and organizational setting in which they work
Deficiencies in structure lead to poor quality, inability to provide good processes of care.
Process is the delivery of health care, the specific way in which care is provided.
Technical and interpersonal processes include correct diagnostic test, correct prescriptions, accurate drug administration, communication, and compassion.
CPGS are Clinical practice guidelines.
CPGS are also called medical practice guidelines.
CPGS constitute a plan for managing a clinical problem based on evidence, in order to guide physicians clinical decisions.
CPGS intentions are to lower costs and get better outcomes.
Cost efficiency is referred to as cost effectiveness.
Cost is efficient when benefits received are greater than the cost incurred.
Optimal quality is when the benefits received are greater than the cost incurred.
Critical pathways are outcome based and patient centered case management tools that are interdisciplinary and facilitate coordination of care among multiple clinical departments and caregivers.
Critical pathways provide a timeline that identifies planned medical interventions along with expected patient outcomes for a diagnosis.
Critical pathways improve quality by reducing errors, improving coordination among providers, streamlining case management, providing assessment data, and reducing variations in practice patterns.
Risk management are pro active efforts to prevent adverse events related to clinical care and facilities operations, focusing on avoiding medical malpractice.
Outcomes are the effects or final results obtained from utilizing the structure and processes of health care delivery.
Outcomes are viewed as the measure of effectiveness of the health care delivery system.
Outcomes suggest overall improvement in health stats.
Measures of outcomes include infection rates, rate of re hospitalizations and patient satisfaction.
Along with access and cost the third main concern of health care policy is quality of care.
The Health care Quality act of 1986 legislation that mandated the collection of national data on legal actions against health care providers, this information allows people to know actions brought against physicians in other states.
Research can influence health policy through documentation, analysis, and prescription.
documentation includes gathering, cataloging, and correlating.
analysis includes program evaluations and outcomes research, look for what does and does not work
prescription includes a course of action that has a desirable consequence.
Access to care is the ability to obtain needed, affordable, convenient, acceptable, and effective personal health services in a timely manner.
Access is a determinant of health status, environment, lifestyle, and heredity factors.
The National Health Interview survey or NIHS and the Medical Expenditure Panel Survey or MEPS are both leading data sources used to monitor access trends.
The MEPS consists of surveys that have data on health care use and expenditures.
Federal and state govt. also collect data
Both low socioeconomic status and minority group members are associated with lower overall health care usage and access.
Racial/ethnic minorities are less likely than their white counterparts to have a specific source of ongoing care.
Hispanics are less likely to have a primary care provider
Nonwhite medicare beneficiaries have fewer cancer screenings, flu shots, and ambulatory visits.
Access to care also relies on having available providers.
Access to care policy helps to ensure that there are enough providers and that their geographic distribution is desirable.
The National Health Service corp provides legislation supporting rural health clinics to expand access.
The National Health Service corp has student assistance programs to emergency medical services.
The National Health Service corp establishes community health centers in inner cities and rural towns.
Two main concerns about the medicare policy are spending must be restrained to keep the program viable, and the program must be made comprehensive by adding services not currently covered or covered inadequately.
Minorities are more likely than whites to face access problems,
Low income, minority status, and cultural habits cause access problems.
Access policies should encourage sensitivity programs to the special needs of minorities and delivery of services to areas populated by minorities.
In rural communities making medical care available to residents is difficult because most health care organizations are established in more urban areas .
The National Health Service Corps helps address personnel shortages in rural areas but only for a limited time.
In order to increase health care access to care in rural areas programs are needed to create incentives for permanent practices in rural areas
Low income mothers and their children have problems accessing the health care system because they lack insurance and generally live in medically undeserved areas, and they are also less likely to receive prenatal care.
SCHIP Federal funds with some state flexibility target health care coverage for children.
People with AIDS and those with HIV have problems obtaining health care.
AIDS patients have difficulty getting insurance because their disease process leads to catastrophic expenses.
AIDS is a challenge to policymakers committed to universal access.
The greatest challenges to health care delivery include increasing costs, lack of access, and concerns about quality.
Health care costs in the US are the highest in the world.
Access is a determinant of health status, demographics and ability to pay.
Quality is assessed through structure, process, and outcomes.
Cost containment efforts are n place to optimize quality and minimize expenditures.
The US does not have a centrally controlled system of health care delivery however it does have a history of federal, state and local govt. involvement in health care and health policy.
The three roles of the government in health care delivery are payer of health care, provider of health care, and a regulator of the health care system.
The role of the govt. as a payer of health care includes medicare, medicaid, CHIP, and TRICARE
The role of the govt. as a provider of health care includes Veterans affairs facilities, public hospitals and clinics, and as safety net providers.
The role of the govt. as a regulator of health care system includes involvement in the political process to make laws, as well as controlling licensure.
Public policies are authoritative decisions made in the legislative, executive, and judicial branches of government.
The Legislative branch is known as the congressional branch and they make laws.
The executive branch is known as the presidential branch and they drive policy for development of laws.
The judicial branch of government is known as the supreme court and they interpret laws.
Public policies are intended to direct or influence the actions, behaviors, and/or decisions of others.
Health policies are public policies that pertain to or influence the pursuit of health.
Health policies are also principles that distribute resources, services, and political influences that impact the health of the population.
Health policies are often the result of public social policies enacted by the government.
Health policies pertain to health care at all levels including policies affecting the production, provision, and financing of health care services.
Health policies can affect groups or classes of individuals as well as types of organizations.
Health policies are used to regulate health care and allocate resources for health care.
Regulative health policies ensure fair competition among providers and services such as seen in the antitrust laws, as well as protect the public as seen in the FDA, HIPAA, and SS act.
Allocative health policies relate to resources for health care such as paying for health care, funding initiatives, and financing research.
Regulatory policies prescribe and control the behavior of particular groups.
States supervise the nation's system of medical education.
States license health professionals as well as oversee the quality of care by health care providers.
States control the administer workers compensation system.
States also govern consumer protection efforts.
Some states regulate control over insurance companies, such as financing, benefit packages, and market packages.
Allocation involves the direct provision of income, services or goods to a group of individuals or organizations.
Two main types of allocation policies are distributive and redistributive.
Distributive allocation policies spread benefits throughout society such as federal funding for research or the hill-burton act.
Redistributive allocation policies take money or power from one group and gives it to another such as in medicare or medicaid.
In the US the government is seen as a subsidiary to the private sector.
The US health care policy features a decentralized role for the states.
The US health policy is pluralistic meaning it has special interest.
The US health care policy has an impact of presidential leadership.
The features of the US health care policy interact or influence the development and evolution of health policy.
Health care is not seen as a right of citizenship or a primary responsibility of government, because the private sector has a dominant role.
Americans prefer market solutions over government intervention.
The complexity of health care makes it difficult for many consumers to make informed decisions.
Health coverage is seen as a privilege.
Role of the government in health care has grown incrementally in response to perceived problems and negative consequences such as escalating cost, excessive regulation, fraud and abuse and conflicting or non funded public directives.
Government is left to fill the gap for the most vulnerable of the uninsured population.
Health policy concerns regarding medical technology include its role in health costs, and its health benefits to people.
There is a constant struggle between the development of technology and the cost of development and access to it.
The government evaluates the value of technology and supports policies that are the most cost efficient and accessible.
The government regulates drugs and devices used.
The US health care system is not a uniform, smooth running system.
The mix of government and private insurance within the US health care system results in a complex and fragmented system of health care financing.
The employed are insured by voluntary insurance through contributions that they and their employers pay.
The elderly are financed by social security tax revenues such as medicare part a and b, and medigaps.
The poor are covered through medicaid via federal, state, and local revenues.
Special populations such as veterans, native americans, and the armed forces have coverage provided directly by the federal government.
Process of legislation regarding policy development and enactment is fragmented.
There are 31 congressional committees and subcommittees.
If senate and house of representatives are split on an issue it must pass through both to be a law.
Medicare and medicaid revisions are not wide sweeping or inclusive, they change incrementally and address some populations but not all, access is still a problem.
States are left to interpret and enact medicare and medicaid revisions individually.
Current health care reform was divided on what should and should not be included in reform.
States have vested interest in health care policy
States develop and implement health care policies involving financial support for the poor and disabled such as in medicaid and SCHIP.
States develop and implement health care policies involving Quality assurance, practitioner and facility oversight such as in licensure and regulation.
States develop and implement health care policies involving regulation of health care costs and insurance carriers.
States develop and implement health care policies involving health personnel training and authorization of local government health services.
States have broad, legal authority to regulate the health care system.
The state can license and regulate health care facilities and professionals.
The state can restrict the content, marketing and price of health insurance.
The state can set and enforce environmental quality standards.
The state can enact controls on health care costs.
States vary in implementation of services.
Some argue that there is too much state control over health policy decisions.
The greater control states have the more difficult it is to enact policy at the federal level .
The fact that states vary in implementation of service leads to inadequacies in health care, and health care access.
State interpretation may not be in line with the intent of the original policy.
Different ethnic, religious, and political groups view health care and policy differently.
Policy often results from compromises designed to satisfy the groups needs.
Groups involved in health care policies include interest groups, employers, consumer groups, alliances, and manufacturers of technology.
Interest groups are the most effective demanders of policies.
Interest groups are adamant about resisting any major change.
Interest groups combine and concentrate the resources of their members to dramatically influence policy making and policy changing to reflect their own interests.
Examples of health care interest groups include the american medical association AMA, the american association of retired persons AARP, and the american hospital association.
Employers concerns are about health care insurance benefits for their employees, dependents, and retirees.
Most small businesses oppose mandates of coverage because of the cost.
Health policies affect labor practices and how business and industry operate.
The interest of consumers are not uniform.
Consumers do not have sufficient financial means to organize and advocate for their own best interests.
Consumer groups advocate and represent consumers of health care.
To overcome pluralistic interests and maximize policy outcomes diverse interest groups form alliances among themselves and with members of the legislative body to protect and enhance the interests of those receiving benefits from government programs.
Each member of the alliance receives benefits.
Policy interventions begin with the identification of a problem where markets fail, or do not function well.
Government regulates and allocates resources of health care through the process of making laws.
Policys are made through the legislative branch of the US govt.
Legislative process of health care law making includes how the idea becomes a law, and how the law is implemented.
The legislative process of health care law making is known as the policy cycle.
Policy cycle the formation and implementation of health policy occurs in a policy cycle compromising five components.
The five components fo the health policy cycle are issue raising/ awareness of a problem, policy design/drafting the bill, building of public support, legislative decision making, building of policy support within the house and senate, and policy implementation.
The components of the policy cycle are shared by the congress and interest groups.
Any senator or house of representative member may propose or sponsor a new law.
An idea is drafted as a bill, the legislators may ask other legislators to become co sponsors.
Co sponsors are assigned a number, title, and are listed.
A bill is introduced into the senate or house of representatives and is assigned to a committee by the authorizing body.
When a bill is introduced into the senate or house of representatives it is reassigned to a subcommittee who reviews it and may combine it with other bills, refer to another committee for review, or hold hearings to get testimony and possible amendments.
The subcommittee then recommend the bill to the full committee.
The full committee reviews the deliberations and recommendations of the subcommittee and may conduct further review, hold more public hearings, or simply vote on the report from the subcommittee.
Committees and subcommittees may recommend, not recommend or table the bill, bills that fail to get subcommittee or committee action die in the committee, which many do.
The legislative process is repeated until the bill is acceptable.
A full committee reporting involves a passed bill and the full committee prepares and votes on its final recommendations to the House or Senate.
Publication of committee report report about the bill is written and published, includes purpose of the bill and its impact on existing laws, budgetary considerations, and any new tax increases required by the bill.
Committee report typically contains transcripts from public hearings, opinions of the committee for and against the proposed bill
Full house or senate review involves the bill being added to the legislative calendar for floor action, full house or senate hears the bill and may discuss, amend, reject, or pass the bill.
Once the bill is approved by the full house or senate by majority vote it is sent to the other chamber, both legislative chambers follow the same procedure however, if amendments are added in one chamber it goes back to the other for approval. Back and forth movement occurs until the bill is approved by both.
The legislative chambers may forward the bill to a conference committee to review amendments if significant.
Conference committee is members of similar committees in both house and senate, and are charged to reconcile differences between the senate and house versions of the bill. If no agreement the bill dies, if a agreement on a compromised version they prepare a report detailing.
Both the house and senate must approve the report of the conference committee or the bill will be sent back to them for further work.
After the bill has passed in both House and Senate in identical form it is forwarded to the president for a signature.
Presidents role in the legislative process includes approving and signing the bill, which becomes the law, vetoing the bill which sends it back to the house or if he does not sign it after 21 days it becomes law if not vetoed.
If less than 21 days left in congressional session and the president does not take action congress can overrule by 2/3 vote, otherwise the bill is dead.
Once legislation is signed into a law, it is forwarded to the appropriate agency for implementation.
New regulation is posted in the federal register and hearings are held to see how the law will be implemented.
The bureaucracy publishes, gathers comments and rewrites regulations.
The program goes to 50 states for enabling legislation.
Local interests begin a new political process to shape the final outcome.
Health policies are developed to serve the public's interests.
National health care is supported, but the idea of federal government running the system is not preferred.
The challenge is finding a balance between government provisions and control and the market to improve coverage and affordability.
Created by: 1298809275
 

 



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