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US Healthcare Exam 3
Terms in this set (47)
What is absolute poverty?
severe deprivation of basic human needs. Food, water, shelter, education, etc. It depends not only on income, but also access to services
What is relative poverty?
lack of the minimum amount of income needed to maintain the average standard of living in the society in which they live
What is the federal poverty line? How is it calculated? What are some issue with the federal poverty line?
Federal Poverty Line (FPL) is an indicator that the United States uses to determine who is eligible for government subsidies and aid.
It is calculated as pre-tax income against a minimum food bundle, multiplied by 3 and adjusted by the consumer price index
The issues with the FPL is that there is no geographic adjustments (cost of living adjustments), it only tracks the consumer price index, and that pre-tax income does not capture services received
What are the main highlights of the ACA?
-Expands health insurance to an additional ~24 million people through a combination of private and public sector initiatives
-offers subsidized private health insurance on exchanges, and encourages states to expand Medicaid to cover more people (government funded)
-subsidies for private health insurance offered to families insurance offered to families making up about $92,000 per year
-Mandates and Fines:
Fines households $695 or 2.5% of income if they choose not to buy healthcare (poor are exempt)
Fines employers with more than 50 employees $2000/ employee if they do not offer employer sponsored insurance
-Health insurance can no longer deny people based off of pre-existing conditions
-Kids under 26 can remain on their parent's health insurance plans
Why does the ACA have subsides? fines? Mandates?
-Health insurance works best when ALL individuals are included
-People who need a lot of medical care in one year are supported by people who do not, and vice versa
-Without the individual mandate, some people might wait until they become sick to purchase insurance, this would increase premiums for everybody else, and more people would be incentivized to wait until they are sick to purchase it - Death Spiral of Insurance
-Employer mandate works as an incentive for employers to continue offering health insurance; the ACA is built on top of our employer-oriented health insurance program
-Subsidies: some people cannot afford health insurance on their own, but are not poor enough for medicaid
What is the number of people expected to gain insurance through the ACA? How will people specifically gain insurance coverage?
Approximately 24 million people will gain coverage from the Affordable Care Act, this will be done through both public and private sectors of insurance
How do the ACA marketplaces (exchanges) operate?
Each state operates its own exchange (marketplace), which is essentially a website, where many different private health insurers can offer plans that are then grouped by levels of generosity: bronze, silver, gold, and platinum
Who qualifies for a subsidy on the ACA?
Anyone can use the exchange, but premium subsidies go to low income people not offered insurance by their employers, and low income people whose employer offers a plan where the employer's share of the premium is 9.5% of their income or more
What is the employer mandate in regards to the ACA?
Employers with 50+ employees must offer some kind of ESI, or they will be charged $2000 per employee
What do essential health benefits and preventative services have to do with the ACA?
Many policies that did not cover all EHBs were cancelled in the fall of 2013, which created political problems
Now the ACA requires all health care plans to cover 10 different EHBs, and 15 different preventative services
Why was Obama wrong that everyone could keep their insurance plan after the ACA?
Almost all of the health plans offered through employers already covered 10 essential health benefits, but only 49% of the plans offered in 2013 in the individual (non-employer) health insurance market covered all of the mandated EHBs
Those that did not offer the 10 essential health benefits were cancelled in 2015, people had to find new insurance plans
What has been the driver of the largest expansions of insurance in the US?
States expanding Medicaid under the Affordable Care Act
Why has the Government Revised Down the Expected Impact of Exchanges for 2016?
Private health insurers lost $2.5B collectively on the exchanges in 2014: enrollees' medical costs exceeded the total (gov & enrollee) premium
Rise in premiums
What are the main ways the ACA is being paid for?
-Reduced Medicare payments to Medicare Advantage plans, hospitals, and other providers (but no reduction in physician payments!)
-Fines/taxes on individuals who ignore the mandate
-Fines/taxes on employers who ignore the mandate
-New fees/taxes on health insurers
-New fees/taxes on pharmaceutical firms
-Excise tax on device firms (2.3% of sales)
-Higher Medicare Part A taxes on households making more than $250,000 a year
-Taxes on "Cadillac" health insurance plans
-Consumers/workers will probably pay for most of the new ACA taxes on Health Insurers, employers, pharmaceutical companies, and medical device firms
Employers and other firms are likely to pass along most, but not all, of the new -ACA taxes to workers and customers through lower wages and higher prices
Who is John Gruber? What did he say that was inflammatory about the ACA? Why is this important?
He was a consultant that helped write Obamacare. He said that the tax on high insurance health plans was inflammatory because it only makes most expensive plans pay a tax and eventually it will hit all employers. This is important because it will eventually get rid of the employer exclusion programs for health insurance.
What are the reasons Medicare adopted the RBRVS payment system? When was it introduced? Which of the goals were successful?
Introduced in 1992
It leveled the playing field between specialists and primary care physicians (not successful)
Slowed the growth rate of Medicare Part B (successful)
Limited out of pocket spending for the elderly (successful)
What are some alternative physician practice arrangements?
Physician Group Practice
Hospitals that purchase a MD's practice
MD that treats only HMO patients
What is capitation?
Capitation is when the practice receives a fixed amount of money per enrollee/patient per month, regardless of what services the MD provides (not common today)
What is fee-for-service?
A predetermined schedule of fees for each service that a physician performs for a patient; the busier the physician, the greater the revenue for the practice
What did Paul Gordon, the ACA listening tour, find from interviewing people across the country about public opposition to the ACA?
They were seemingly misinformed about what exactly was going on with the healthcare reform, they had many different opinions on the issue, but no real solutions
He proposed that doctors should step in and help their patients better understand the ACA..no politics, just the facts about the reformed system
According to Dalen et al. 2015, why do so many Americans oppose the Affordable Care Act? Where did the majority of American obtain their information about the ACA?
Many Americans oppose the ACA because not only do they oppose a government role in healthcare, but also because they oppose the individual mandate that all people must have insurance
He found that a more than 60% of Americans received their information about the ACA from Republican candidate ads on TV, which often shed a negative light on it (Republicans are often less trusting of the government, and do not believe they have a place in health care)
What has happened to cost of healthcare in MA?
Increased with rapidly rising healthcare costs. Massachusetts was, and still is, the state with the highest per capita health care spending in the U.S.
What has happened to the number of insured in Massachusetts?
Massachusetts now has the highest number of people insured in the country at almost 99%
Why do people think studying Massachusetts will help us understand what will happen with the ACA?
The closest real-world example to the Affordable Care Act is the health reform plan implemented in Massachusetts in 2006. Even though the ACA has a 50-state focus, the plans are very much alike. MA passed similar law, similar ideas to indv mandate and employer mandate, premium subsidies on state run health insurance exchange, medicaid expanded, increased medicaid funding
Is it clear that the ACA has caused the recent slowdown in medical spending?
IPAB Panel, cadillac tax, and voluntary programs have been implemented to slow down the growth rate of healthcare spending
It is too early to tell, but ACA spending is expected to drop by $190B over 10 years
How have employers said that they'll deal with the cadillac tax?
-Trying to avoid it; that concern is accelerating an already strong trend toward having workers foot a greater share of their overall health-care costs in the forms of higher deductibles, copayments and coinsurance charges—whose dollar amounts are not factored in when calculating the tax.
-More companies are also considering other cost-saving measures, such as encouraging use of telemedicine services and giving employees incentives to go to certain medical providers
Why is there controversy about the IPAB?
They can redefine "rationing" to mean to deny care for a cost ineffective service, therefore would block certain services; 60 votes in the senate are required to block an IPAB proposal o r it becomes the law, and there is no way to challenge it judicially
What is the Independent Payment Advisory Board (IPAB)?
A board of 15 appointed members who will propose ways to reduce "excess" Medicare spending growth without "rationing care, increasing revenues, changing benefits, or changing eligibility"
What will the ACA do for the Medicare part D donut hole?
Nearly 4 million Medicare patients reach the donut hole
The ACA will reduce the coinsurane rate in Medicare coverage to 25%
Explain how hospitals might benefit from the ACA
Potentially large reduction in hospital charity care costs (uninsured care) due to fewer uninsured patients
Hospital charity care is 2.4% of hospital expenses in MA, 5.8% nationally
ACA will reduce hospitals' uncompensated care costs by $4.2B per year in states that are expanding Medicaid, and by $1.5B in the non-expanding states (16% decrease)
Could boost hospital net income by 0.4-1 percent, which is a large change
What two factors drive the majority of ACA costs?
-Subsidies offered to lower income families/people
-Covering 100% of Medicaid expansion costs for the first 3 years, then 90% thereafter
How much is the ACA expected to cost the federal government over the next 10 years?
ACA premiums rose, on average, 22% from 2016 to 2017, what has happened to subsidies over this same time period?
Subsidies also rose but at a faster rate which caused many premiums (all the way from bronze to gold) to be considered "Zero-premium plans" because the subsidy was covering the whole premium cost
What is RBRVS? Beyond writing out the words, why does this exist?
Resource-Based Relative Value Scale; it assigns procedures performed by a physician or other medical provider a relative value which is adjusted by geographic region (so a procedure performed in Manhattan is worth more than a procedure performed in Dallas). This value is then multiplied by a fixed conversion factor, which changes annually, to determine the amount of payment.
-intended to improve and stabilize the payment system while providing physicians an avenue to continuously improve it.
-The RBRVS was designed to address the soaring cost of healthcare in the United States; the inequities between geographic areas; time in practice; and the current payment schedule
MDs can choose to participate in Medicare (accept patients), what % accept Medicare patients?
96% of physicians choose to participate in Medicare
What is a Relative Value Unit? What is the $ value of 1 RVU? Who sets the $ value?
RVU- Relative value units (RVUs) are a measure of value used in the United States Medicare reimbursement formula for physician services. RVUs are a part of the resource-based relative value scale (RBRVS).
Congress sets the RVU for how much physicians should get reimbursed
How is a current procedural terminology code related to an RVU? what is a CPT?
Current Procedural Terminology codes are what is used to categorize patient visits based on what was performed; office visit, consultation, surgery
It is related to RVUs because each CPT code is assigned 3 seperate RVUs
Product of the RVUS for the CPT and the payment per unit determines how much the MD is paid for that specific visit
What are the three separate RVU components that go into calculating a reimbursement for a given CPT? How is geography related to the reimbursement?
3 components: physician work, practice expense, and malpractice expense (each is assigned an RVU)
Reimbursement is adjusted for the geographic location; cost of living
True or false, under RBRVS, specialists make more per hour than PCP? Explain why you selected T or F
True, they do more procedures which have higher RVUs & CPTs so the monetary value of them is higher
How is private insurance reimbursement related to RBRVS? What about Medicaid reimbursement rates?
Private insurers reimburse physicians (on average) 25% more than the RBRVS value
Who was the first state to restrict the practice of medicine to those with licenses? When did this happen? Was there opposition? From whom?
Apprentice-trained physicians in Georgia in 1821 were opposed to the restriction on those with licenses
How did the AMA contribute to changing medical education? What about Carnegie?
In 1904, the AMA established the Council on Medical Education which addresses the needed educational improvements and standards in medical education, and Journal of the American Medical Association (JAMA) which published medical school state licensing failure statistics and grouped schools by their failure rates; demanded poor schools to improve or resign the association
In 1905, the Carnegie Foundation supported AMA reforms - allowed them to examine all 155 US and Canadian medical schools' entrance requirements, faculty, laboratories, and hospital relationships
What is the Flexner report? What was its impact? Who funded it? What were its main conclusions? Who did it hurt? Who did it benefit?
The Flexner Report is detailed critique on medical education in the US & Canada outlining their assets, deficits, and recommendations
Propose the reduction in the number of medical schools
Promoted state licensing legislations and standardized curriculum
What is an MD? A DO? What are the similarities and differences?
MD is a doctor of medicine; requires 4 years after college
DO is a doctor of osteopathy; requires 4 years after college plus an additional 300-500 hours of training in osteopathic medicine
MD has broader recognition, especially outside of the US
Describe the Obama administration's strategy for holding the May 2009 health care reform meeting with the president and all interested parties. What was the administration trying to accomplish, and what was it trying to avoid, based on lessons learned in the past?
All interested parties were brought in to be able to voice their opinions on the matter to be able to avoid future conflict. Insurance companies, pharmaceutical companies, and medical companies were interested in the financial gain that they could receive if this reform was passed
In what ways were the demands of the health insurance lobby in opposition to the health care reforms candidate Obama proposed during the 2008 campaign? Why do you think President Obama eventually agreed to the demands from the lobbying groups? Do you see any other options the president might have explored? Do you think this type of political compromise is in the best interest of American citizens? Explain your answer.
Health insurance lobbyists demanded that the individual mandate be a part of the reform. I think that he agreed because he knew any opposition to his ideas expressed by the health insurance companies would be public, as they had enough money to advertise against him, and could have cost him the election. At the time, without having support from any other big lobbyists, he needed the support from the health insurers. I do not think that it was in the best interest of American citizens, but rather the best interest of the health insurance companies, as they would be selling more and thus increasing their own revenue.
Why were health care reform activists like Dr. Margaret Flowers angry with Sen. Baucus during the committee hearings? Do you feel their protests were justified? What could Sen. Baucus have done differently? What might have been the outcome?
The American people were not being heard, but rather the health insurance lobbyists. I can understand their anger and frustration, as it was clear that this was primarily about funding and not so much about actual reform. I think that Senator Baucus could have let at least one of the 41 people invited to participate be someone of a more neutral role; not one who was in it for the money. I think that if someone was there and voicing the opinion of a typical American citizen, nobody/ less people would have been outraged, and it could have ended moreso with the American people in mind.
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