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Dr. Logan's Nonsense (Part 2)
Terms in this set (56)
In the manufacturing sector, health care is ranked WHAT in amount of money spent?
What about in personal consumption?
What about in
US public expenditures?
3rd (after food and housing)
1st (about 25%)
True or false: the United States has the highest amount of healthcare spending and highest rate of doctors visits among other countries.
FALSE; highest amount of spending, but don't go to the doctor as much
Where does most of the money in healthcare go?
What health-related conditions receive the most health care dollars (i.e. what bodily system)?
Where did health insurance originate and why?
Europe to lighten financial burden of sick people; focused towards low skilled, low income workers
Where did the first government health insurance program originate?
The U.S. Healthcare system stems from which original program?
European program (linked to employment)
What are the three categories of US health insurance?
Voluntary = private, usually denoting industrial employment
Social = government entitlement program linked to previous employment
Public Welfare = lack of employment, low income, etc.
What is the difference between general insurance and health insurance?
General insurance assumes risks are independent of each other
Health insurance does not make these assumptions
What is moral hazard?
a temptation exists to use the insurance
if you are insured for a service, you will use more of it
What is the benefit structure of insurance in order to negate moral hazard?
Health insurance usually pays less than total loss incurred by having patients pay out-of-pocket costs
What is a deductible?
Amount of money that must be paid by patient before insurance becomes active
What is a copayment?
Fixed amount paid for a healthcare service
What is coinsurance?
Certain percentage paid by patient and insurance
What is a premium?
The monthly amount you pay health insurance company to maintain coverage
What is experience rating in regards to premium determination?
Premiums based on demographic characteristics of employer group and actual experience of the group in that plan in prior years
used by most health insurances and fee-for-service plans
What premium determination method is most commonly used by health insurances?
What is community rating?
used by most HMOs
because they face price competition
What premium determination method is most often used by HMOs?
What is adjusted community rating?
Single rate applies to all small groups in the market, with limited adjustments allowed for specified case characteristics (e.g. 50 employees or less)
What are the three distinct categories of voluntary health insurance?
Blue cross blue shield
Private or commercial
What does basic insurance cover?
Limited protection for most expensive services, such as inpatient and outpatient services
What does major medical insurance cover?
expenses associated with routine types of medical care, such as physician office visits, medications, ambulance care, etc.
What do comprehensive plans cover?
Combination of basic and major medical plans
What does a hospital indemnity plan cover?
specified payments for each day of inpatient hospitalization regardless of actual expenses
linked to length of stay, not services
not generous payment
What are managed care plans?
plans that provide comprehensive coverage in return for a pre-paid fee (HMO, PPO, etc.)
What are the main differences between HMO, PPO, EPO, POS, and Network?
HMO = must choose PCP; need referral for specialist; minimal copayments and coinsurance
PPO = doesn't need to choose PCP; no referrals needed for in-network; most likely will have copayments and coinsurance
EPO = must use doctors and hospitals in-network; no referrals needed; rates usually lower than HMO and PPO
POS = combines PPO and HMO; must choose physician, needs referral, can see out-of-network but at higher out-of-pocket costs
Network = group of hospitals or healthcare workers agree to provide services to health insurance plan members at a discount
Which managed care plan allows a patient to see doctors in-network or out-of-network as needed?
What are the two basic benefits of worker's compensation?
How are premiums usually determined?
cash replacement of portion of wages due to disability; payment for all or part of medical care
What event in NYC helped lead way for worker's compensation legislation to be passed?
Triangle Shirtwaist Factory Fire
True or false: the employee pays for worker's compensation insurance.
What is Medicare?
Who is eligible to receive it?
single payer, federally-administered and financed program
> 65 years old, disabled, end stage renal disease, and ALS victims
What are the different parts of Medicare?
Part A = Hospital Insurance
Part B = medical insurance
Part C = Advantage Plans (allows private insurances to offer comprehensive services; many HMOs have dropped out)
Pard D = Prescription drugs
What is the "donut hole" of Medicare?
there is a temporary limit on what the drug plan will cover for drugs, then patient is in a coverage "gap," where insurance will cover less for drugs until they reach a certain amount
A rough example: Insurance pays for drugs up until $1000. Between $1000 and $3000, patient is responsible for 50% of drug costs. After $3000, insurance resumes paying for most of drug costs.
What is the purpose of the "donut hole" in Medicare?
Protects severely ill patients from catastrophic expense in prescription drug charges
What is Medigap?
Medicare Supplemental Insurance-to pay for medical services and out-of-pocket charges not covered by Medicare
True or false: Medicare is a form of charity.
FALSE; it is an entitlement program
Medicaid is a form of charity
Who funds Medicaid?
federal and state government
Who funds Medicare?
federal government only
What is transfer payment in regards to Medicaid?
Services are provided as a welfare benefit in lieu of cash
What is CHIP?
True or false: it is an example of social insurance.
Children's Health Insurance Program
FALSE; public welfare
In regards to non-financial resources for health services, what is innovation?
Innovation = medial technology advancements
Development = biomedical research
Diffusion = spread of technology into society (
The Life Cycle of Technology
A national health insurance is based off of models from which two countries?
What 4 positive aspects do they have?
Germany and Canada
Universal access, high quality, high volume, and cost controls
What did Obama's Children's Health Insurance Reauthorization Act of 2009 do?
Expanded healthcare program to additional children and pregnant women, including legal immigrants, without a waiting period
What are the 3 says most Americans get health insurance?
Online marketplace with ACA
What are associated health plans?
Cheaper, loosely regulated plans allowed by Trump, based on the idea that small businesses band together to get better rates from insurance companies
What is Quality Assessment and what is it based on?
Process by which quality of care is measured
1)Structure (adequacy of providers and facilities)
2) Process of Care (way which care is provided; patient-doctor interactions; lab tests performed)
3) Outcomes of Care (midpoint and end results)
What are the most important indicators of quality assessment?
What is quality assurance?
quality measurement of activities with feedback mechanisms to provide continual quality improvement
Reviews AND affects services
What are 5 examples of healthcare quality assurance measures?
Compliance with Standards
Professional Review Organizations
What is reimbusrement-related utilization review?
Patient must receive prior authorization before performing certain surgical procedures
Total Quality Management incorporates what 3 aspects?
Risk management, quality assurance, and patient satisfaction
What are Diagnosis Related groups?
classifies hospital cases into groups that determines how much Medicare pays hospital within each group
What is the Prospective Payment System?
establishes reimbursement rates for health care services based on a fixed amount
DRG for inpatient hospital services is an example of a prospective payment system
What does the Professional Review Organization do?
Uses utilization review to guard against unnecessary admissions, medical record miscoding, etc.
What does the Professional Standards Review Organization do?
monitors government health insurance programs
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