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.

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Health Insurance began as

a form of disability coverage that provided income during temporary disability due to bodily injury or illness

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During WW1 anti german sentiment opposed a

national health care plan.

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During the great depression social service took

center stage.

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AMA & AHA opposed

any plans to protect Physician wages

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AMA & AHA 1948

largest and most expensive lobby campaign against national insurance

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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

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private health insurance has prevented

a national health care program

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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

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The American Hospital Association (AHA) supported group hospital plans and

coordinated them into a Blue Cross network

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Blue Cross Network transformed insurance from a mechanism to reimburse for lost wages to one that

reimbursed providers for the cost of medical care

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Blue Cross was non profit and there were no

shareholders.

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Control of Blue Cross plans was transferred to an independent body forming

Blue Cross Association.

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In 1946 Blue Cross was in

43 states and serving 20 million people.

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Blue Cross was the birth of

commercial insurance.

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Commercial insurance companies follow

Blue Cross structure.

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Private Insurance industry included

hospital plans, and was AHA endorsed for ONLY hospital care.

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From 1940-1950 hospital insurance rose from

9% to 57%

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In 1939, the California Medical Association started the first

Blue Shield plan

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Fist blue shield plan was designed to pay

physician fees.

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Blue Shield plans were aimed at protecting the

medical profession's own financial interests.

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Blue Shield was AMA

endorsed.

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By 1974 Blue Cross and Blue Shield

merged, today they are a joint corporation, and are in almost every state.

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During World War II, employees accepted employer-paid health insurance to

compensate for the loss of raises

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Congress made employer-provided health coverage

nontaxable, was equivalent to getting more salary without having to pay taxes

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The US Supreme Court ruled that employee benefits were a legitimate part of

union-management negotiations

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By mid-1950’s commercial insurance companies offered

health insurance.

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Today – 850 health insurance companies contract with millions of employers to

provide coverage.

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Health insurance through the employer is the

primary source of payment of healthcare services in the U.S.

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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

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Health Care Expenditures are

money that is spent in the process of doing business

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Health Care Expenditures include the

cost of resources required to maintain a health care delivery system

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Goal is to keep health care expenditures

down.

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Cost is related to the charge to the patients and insurance companies

willingness to pay.

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Expenditures occur in 4 major areas

Financing,Technology and supplies,Facilities,Personnel

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Financing

source of money used to run a business

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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).

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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.

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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

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Heath Insurance desensitized both consumers and providers to the

price of services.

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Effects of financing and insurance include

demand for services, covered services expand rapidly, growth of medical technology.

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Negative effects of financing and insurance include

moral hazard (ability to pay = more utilization), provider-induced demand (reimbursement= create demand)

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Moral Hazard + provider-induced demand =

increased health care expenditures and wasted resources.

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Supply-side rationing

restricting the availability of expensive medical technology and care (i.e. insurance will only pay for some procedures)

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Demand-side rationing

utilization of services curtailed due to lack of insurance; limited access to care

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Today's complexity of financing is caused by

many payers, many forms of payment, many programs and many reimbursement options.

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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.

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Patients finance their

own care and pay for those who can't afford it.

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Many employers attach health care to

wages, medicare tax is also deducted from pay as a prepayment for when 65.

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General taxes subsidize health care for

poor.

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Cost-shifting and tax subsidies

pay into catastrophic health for the uninsured.

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Sources of financing health care include

private insurance programs, public insurance programs, uncompensated or charity care.

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Types of insurance include

private (voluntary/personal) and public (government).

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Private health insurance includes

group insurance, self-insurance, individual private, and managed care organizations.

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Public health insurance includes

medicare and medicaid, and state children's health insurance.

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Financing is

any mechanism that gives people the ability to pay for health care services

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In most cases, financing is necessary to

have access to health care

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Insurance

method of payment for health care services

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Insured

person for whom the policy is for

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Insurer (3rd party payer)

employer or organization responsible for reimbursement of services

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Provider

individuals providing care or services

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Benefits/coverage

plan that employee chooses; contains the conditions and services under which payment is made

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Premium

cost (usually by monthly fee) that is paid by the insured for coverage

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Policy

legally binding contract of the insurance plan

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Enrollment period

time period when employees can take advantage of benefits

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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

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Copay

at time of service; patient pays for a portion of the services up front

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Coordination of benefits

clause that determines which insurance pays for services if insured has more than one

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Out of pocket

patient pays provider directly from own savings – no insurance involved

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Fee for service

insured purchases insurance to cover certain benefits; pay provider at time service is provided

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Pre-payment

insured pays fixed, predetermined amount for services rendered

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Coding

system of identification of diagnoses, procedures and services that were provided to the patient; describes the services

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Billing

charges posted to patient’s account for services rendered

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Claims

form sent to insurance company explaining charges incurred by the patient

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Explanation of Benefits (EOB)

a statement sent to the patient that explains which claims were paid and at what level

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Risk

the possibility of substantial financial loss from some event, where probability of occurrence is small

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Insurance

protects against risk

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Insured (enrollee/beneficiary)

an individual protected by insurance

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Insurer

an insurance agency that assumes the risk

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Underwriting

evaluates, selects/rejects, classifies, and rates risk

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A insurance policy premium is based on

shared risk.

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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

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Restriction of usage

reduce the overuse of services, often times through the use of primary care providers working as gatekeepers.

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Limitation of access

want to spread the risk

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Major concern of risk management is how to effectively control rising

health care costs.

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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.

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Due to risk management many people who are most in need of health insurance

are not covered.

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Cost Sharing

Rationale is to control the utilization of health care services – if you pay, chances are you will be more responsible in utilization

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Insurance requires some type of

cost sharing.

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The insured assumes at least part of the

risk.

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Cost sharing reduces the misuse of

insurance benefits.

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Findings of the Rand Health Insurance Experiment

cost share lowers utilization without lowering quality

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Three main type of cost sharing in private health insurance include

premium cost sharing, deductibles, and copayments.

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Premium cost sharing

both parties pay premium.

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Deductibles

payment before insurance pays

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Copayments

out of pocket expenses patient contributes to care.

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Coinsurance

percent of bill insurance pays after deductible.

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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

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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

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Third-party payers

insurance companies, managed care organizations, BlueCross BlueShield, government

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Reimbursement

payment made by third-party payers to the providers of services

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Types of reimbursements include

Fee for Service, Package Pricing, resource–based Relative Value Scale, reimbursement under Managed Care

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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.

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Package pricing (bundled pricing)

number of related services in one price, reduce provider induced demand because fees are inclusive of all bundle services.

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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.

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Discounted fees

used by PPOs

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Capitation

Used by HMO's, per member per month fee to cover all needed services, prudent delivery of services, minimize provider-induced demand.

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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.

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Prospective reimbursement

uses pre-established criteria to determine in advance the amount of reimbursement.

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Four main prospective reimbursement methods are

Diagnosis related groups (DRG), ambulatory payment classifications (APC), resources utilization groups (RUG), home heath resources group (HHRG)

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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.

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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.

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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.

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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.

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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.

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Two functions of financing are

purchasing of health insurance and payment of services

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Sources of financing health care are

private insurance programs, public insurance programs, and uncompensated or charity care.

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When ACA is fully implemented in 2014, burden of HC spending will shift to

taxpayers.

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Most popular form of financing health care is through

private insurance, which is mostly employer based.

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Private or voluntary/personal insurance types include

individual private, group insurance, and self insurance.

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High deductible health plans can also be group or

self-insurance

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Managed Care organization can also be individual as well as

group or self-insurance.

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Public or government insurance types include

medicare and medicaid, state children's health insurance.

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Private insurance is voluntary insurance meaning that it is not

mandatory.

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Private insurance is available in single or

family plans.

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Most private insurance is

employer based.

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There are many different types of private insurance providers such as

Commercial, blue cross blue shield, managed care organizations, HDHP.

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Individual private insurance is where the individual pays directly to

the insurance company.

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Those covered by individual private health insurance can pick options of coverage based on

needs.

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Those with individual private health insurance may include

early retirees, and self-employed individuals.

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In individual private health insurance risk is

individually determined.

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Within individual private health insurance premiums are determined by

coverage picked.

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Within individual private health insurance high risk people are often unable to receive

coverage.

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Group insurance is offered through an

employer, union, or professional organization.

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Group insurance anticipates large numbers of

people in a group and will buy insurance through a sponsor (employer)

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Within group insurance cost and risk are distributed

equally among the insured.

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Group insurance typically includes major medical and

comprehensive coverage.

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Self Insurance is where the employer

covers itself.

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Self-insurance occurs when large employer's work forces are

large and diversified enough.

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Those with self-insurance can predict their own

medical experience.

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Those with self-insurance can assume risk and

pay all claims incurred by employees.

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Within self-insurance high losses are covered through reinsurance which is

purchased insurance from a private company.

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Consumer Driven Health Plans (CDHP) feature high

deductibles or upfront costs in exchange for low premiums, and different ways of paying.

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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.

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High Deductible Plans (HDHPs)

Pay less for health care but still covered for catastrophic illness.

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HDHPs feature low

premiums but higher deductibles, as well as no copays for MDs.

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Within HDHPs preventative care is typically not

covered.

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Within HDHPs yearly cap is based on

out of pocket expenses.

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The two main types of high deductible health plans or HDHPs are

HSA or health savings account and HRA health reimbursement arrangement.

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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.

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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.

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Within a HDHP/HSA there is a tax advantage because the account is

tax exempt.

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A HDHP/HRA is a health reimbursement arrangement it is a employer funded account that is tax

exempt payments made for qualified medical expenses.

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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.

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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.

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Managed Care Organization is a type of

private insurance.

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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.

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The most critical factor in differentiating between the types of MCOs is the

choice of providers.

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Types of managed care organizations include

health maintenance organization HMO, preferred provider organization PPO, exclusive provider organization EPO, and point of service organization POS.

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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.

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Health Maintenance Organizations are restrictive meaning

in network providers and services are covered only.

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HMO's are referral based meaning they are

coordinated by an HMO provider or gatekeeper, who make all the decisions.

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HMO's focus on wellness care feature

preventive and screening services, "health maintenance" within the organization.

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HMO models include

staff model, group model, network model and independent practice association or IPA model.

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HMO staff model features fixed salaried MD on staff in a

large HMO.

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A HMO staff model operates clinics and

sometimes hospitals, that service only those enrolled in HMO.

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Staff model MD covers all specialities in order to

deliver care.

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HMO staff model features more control over practice and

MDs.

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In an HMO staff model it is easier to monitor

utilization.

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In an HMO staff model you need a large number of enrollees to

cover costs.

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Enrollees in an HMO staff model are limited on the MDs

they can go to.

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HMO Group model contracts with a multi-specialty

group practice.

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In a HMO group model MDs are not employed by the HMO but by a

group practice.

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In an HMO group model they contract separately with

one or more hospitals for specialty services.

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In an HMO group model while not exclusive services, HMO has some

control over utilization.

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In an HMO group model the HMO pays group practice to

provide services.

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Independent practices can also treat

non-HMO patients

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HMO may own group practice as a separate corporation but

one that is administratively tied to the HMO-service exclusive to HMO members.

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HMO network model contracts with

more than one medical group.

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HMO network model is suited for operations in large metropolitan areas and across widespread geographic regions where

group practices are located.

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In an HMO network model the patient chooses

which provider.

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In an HMO network model the group practice is paid by

capitation.

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In an HMO network model the group practice is responsible for providing

all MD services.

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In an HMO network model doctors can make referrals to specialists but

responsible for reimbursing them for the referrals not the HMO.

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In an HMO network model there is low utilization control since

no central overseeing agency.

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An independent practice association or an IPA is an intermediary between an

HMO and providers.

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An IPA is a risk

bearing entity.

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The IPA is paid a capitation fee by the

HMO.

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In an IPA the HMO contracts to the IPA instead of

directly with MDs

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An IPA establishes contracts with both independent solo pracitioners and

group practices with large numbers.

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IPAs are independently established by

MD groups.

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In an IPA HMOs may create and invite area

MDs to participate

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An IPA is hospital based and structured so that only certain

practices may participate.

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IPA assumes the responsibility for

utilization management and quality assessment.

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In an IPA MDs are responsible for providing services but logistics of arranging MD services are shifted to the

IPA.

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Preferred Provider Organization or PPO is the

most flexible.

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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.

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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.

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A PPO is more flexible but the premium is

higher to pay for this option.

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In a PPO group practice is paid by

discounted fees.

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In a PPO there is a deductible driven

plan that is paid annually.

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In a PPO patients can use out of

network providers, but there is a higher out of pocket cost to the enrollee.

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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.

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A PPO guarantees volume of business to hospitals and MDs who in return accept

reduced fees.

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In a PPO MDs have no personal risk and get fee for

service at an agreed upon reduced rate.

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In a PPO a hospital is insured a

patient population.

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A POS a point of service organization is a combination of a

HMO and PPO.

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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.

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In a POS providers paid by

capitation.

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In a POS gatekeepers may be used to

control utilization.

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In a POS it is referral based, pick your primary care practitioner and specialty care with referrals for

out of network providers.

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A POS is a copay

driven model.

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COBRA

Consolidated Omnibus Budget Reconciliation Act of 1985

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COBRA is aimed to reduce gaps in

coverage for individuals between jobs and their family.

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Due to COBRA employer must extend benefits to former employees for

18 months.

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COBRA may be extended to spouse or dependent up to

36 months.

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In COBRA you must pay entire premium but it is still

cheaper than purchasing on own.

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Private insurance is

any form of insurance NOT subsidized by the government, includes individual and employer-based.

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Many types of health care plans available but they are usually

employer driven.

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Premiums, deductibles and co-pays

vary.

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Public insurance is government

financed.

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Accounts for 45.4 percent of total US health care expenditures

public health insurance

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Piecemeal was the addition of new programs and

adds to the taxpayer's burden.

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In 2010 31 percent are covered by

public insurance.

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Public financing supports categorical programs, not public in the sense that

it can be used for uninsured or all people.

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Categorical programs are each designed to benefit a

certain category of people who meet the eligibility criteria to become beneficiaries.

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Medicare and medicaid are categorical programs and were created under the

social security amendments of 1965.

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Before 1965, private health insurance was the only

widely available source of payment for health care.

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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.

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Early debates on health reform occurred in the 1950s but americans did not want

government overseeing health care.

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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.

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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.

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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.

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The Kerr-Mills Act was a failure to

implement, it was deemed ineffective.

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1964 President Lyndon Johnson made public health insurance a

top priority.

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AMA urged congress to expand

Kerr-Mills Act.

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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.

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Medicare is

title 18 of the social security act.

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Medicaid is

title 19 of the social seurity act.

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Medicare and Medicaid were instrumental in covering

select populations.

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Medicare and medicaid are financed by the government but delivered by

private providers.

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Medicare and medicaid put a huge burden on

gross domestic product.

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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.

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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.

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Medicare does not cover

everything.

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Medigap policies cover

medicare deductibles and co-payments, may pay for services not covered by medicare.

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Medicare Part A

Hospital insurance HI

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Medicare Part B

Physician insurance/ Supplementary insurance SI

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Medicare Part C

Medicare advantage

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Medicare Part D

Prescription drug coverage.

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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.

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Medicare does not require a

primary care MD

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Medicare can see any

doctor, hospital, other providers and facilities but must be medicare approved.

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Medicare covers most

medications.

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Those with medicare may also have other coverage through

employer, union, etc.

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Those with medicare pay

deductible, and coinsurance, out of pocket.

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In medicare the timing of benefits is determined by a

benefit period.

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Benefit period begins on the day a beneficiary is

hospitalized.

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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.

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A beneficiary can have unlimited

benefit periods.

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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.

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Medicare acute hospital benefits include all expenses paid for first 60 days after

deductible met, deductible applies for each benefit period.

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Medicare acute hospital care requires a copayment from

61-90 days, max benefit period is 90 days.

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For medicare acute care hospital benefits have a max benefit period of

90 days.

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Acute care hopsital benefits includes a higher copay after

90 days.

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Acute care hospital benefits include a lifetime reserve of 60 days after

90 days.

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Medicare acute care hospital benefits include psychiatric services of

190 days lifetime.

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Medicare acute care hospital benefits include private funds, medigap insurance and medicaid kicks in after

medicare is exceeded.

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Medicare certified SNF benefits eligibility begins after

3 consecutive days of hospital stays.

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Medicare certified SNF benefits have a 100 days

maximum.

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Medicare admission to SNF must be within 30 days of discharge from

hospital and related to hospitilization.

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Medicare SNF benefits include 100 percent of payment for the first

20 days, then a copay from days 21-100.

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Medicare home health benefits require the patient to be homebound and

require intermittent or part-time skilled nursing care or rehabilitation care.

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Medicare home health benefits cover up to

100 home visits after hospitalization.

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Medicare home health benefits cover durable medical equipment at

80 percent.

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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.

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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.

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The legislative chambers may forward the bill to a

conference committee to review amendments if significant.

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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.

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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.

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After the bill has passed in both House and Senate in identical form it is

forwarded to the president for a signature.

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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.

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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.

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Once legislation is signed into a law, it is forwarded to the

appropriate agency for implementation.

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New regulation is posted in the federal register and hearings are held to see how the law will be

implemented.

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The bureaucracy publishes, gathers comments and

rewrites regulations.

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The program goes to 50 states for

enabling legislation.

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Local interests begin a new political process to

shape the final outcome.

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Health policies are developed to

serve the public's interests.

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National health care is supported, but the idea of federal government running the system is

not preferred.

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The challenge is finding a balance between government provisions and control and

the market to improve coverage and affordability.

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Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.

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Or sort by any of the columns using the down arrow next to any column heading.
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