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US Health Care Systems Midterm Study Guide

by: Samantha Notetaker

US Health Care Systems Midterm Study Guide HSA3111

Marketplace > University of Florida > HSA3111 > US Health Care Systems Midterm Study Guide
Samantha Notetaker
GPA 3.8

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About this Document

This covers Chapters 1-4,6,7, and 9
Dr. Marlow
Study Guide
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This 9 page Study Guide was uploaded by Samantha Notetaker on Sunday October 2, 2016. The Study Guide belongs to HSA3111 at University of Florida taught by Dr. Marlow in Fall 2016. Since its upload, it has received 98 views.


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Date Created: 10/02/16
1 US Health Care Systems - Midterm Exam Review Major Characteristics of the U.S. Health Care System 1. No central governing agency 5. Government as subsidiarity  Financed privately and to the private sector publicly  Unlink other countries,  Many independents the U.S private sector (making it incredibly plays a bigger role than complex) the government does 2. Technology-driven and 6. Fusion of market justice vs. focuses on acute care social justice  Always new technology  Fair distribution and the the doctors want to well-being of the community are equally play with  HOWEVER, fancy important technology raises costs  Problem: some people 3. High in cost, unequal in are still left out access, and average in 7. Multiple players and balance income of power  The government  Many different people spends a lot of money with many different on health care interests to guard  BUT, lots of people still  Good thing: not only don’t even receive the one individual controls basics everything  It’s too expensive, too 8. Quest for integration and accountability complicated, and still doesn’t accomplish  Using primary care to what is should help organize 4. Imperfect market conditions  Patient and provider  Patients don’t choose are both accountable the doctors they are 9. Access to health care allowed to see, their selectively base on insurance does! insurance coverage  THEREFORE, supply  We have lots of health and demand is care, but only those irrelevant with insurance or lots  People are uniformed, of money can use it insurances play  The uninsured don’t favorites with have much of a choice providers, and there 10. Legal risk influences are hidden fees practice behaviors 2  People like to express making the career of a their legal rights, health professional look less appealing 11. Subsystems 1. Managed care – controls utilization and costs of health care services by contracting with providers and paying through capitation 2. Military – available for the military! Covers active-duty, retired, and families 3. Vulnerable populations – for the poor and uninsured (receive care through safety nets) a. Medicare and Medicaid 4. Integrated delivery – network of providers 5. Long-term care – for chronic issues and disabilities 6. Public health – for the community! Vulnerable Populations Medicare  Serves the elderly, disabled, and those in end stage renal failure Medicaid serves more people  Serves low income families and people with certain special needs CHIP is also considered a vulnerable population Historical Context of Health Care Delivery in the U.S. Role of the government in the Role of government in other U.S. = government as secondary countries = government is with the private sector taking on dominant role the dominant role Preindustrial era  Almshouse – (poorhouse) a place for the destitute: elderly, homeless, orphans, ill, and disabled  Asylum – basically a psychiatric facility  Pesthouse – people who had a contagious disease that needed to be contained  Dispensaries – free basic medical care to those who could not afford it Medical training Medicine was more of a trade rather than a practice, and it was not as heavily reliant on science as it is now. ***Flexnor Report: reformed medical education (1910) – Post industrial History of Medicare and Medicaid (1965) First form of government funded health insurance 3  It was created for the elderly, the unemployed, and the poor History of Private Insurance st 1 form of private insurance: J.F. Kimball at Baylor University Blue Cross – hospital plan Later merged to be Blue Cross Blue Shield Blue Shield – physician plan that we know today HMO Movement Began in (1973) during the postindustrial era Health, Beliefs, and Values Health care is very important  American people prefer the private sector to be the dominant role and have the government as subsidiary  Lots of social cultural variations  When It comes to technology in the U.S., doctors and people generally like to use the newest, improved technology (however, this makes costs go up) Medical model – physical Social/alternative model – social Multidimensional health – physical and mental Holistic medicine – seeing the patient as a whole person; physical, social, mental, and spiritual Medical determinants - focuses solely on the physical, treating the illness Social determinants - takes into account demographics, SES, behavior, and community inequalities Both - interventions  Policy interventions – safety for products, food, water, and environment  Community-based interventions – targeting the community  Health care interventions – improving health care (possibly by adding new technology)  Individual -level interventions – (self-explanatory) Market Justice versus Social Justice Market Justice Social Justice Health care seen like economic good Health care seen as social resource Individual responsibility Active government involvement The people know best Ability to pay shouldn’t matter Free market Medical care is a basic right for everyone Goals of Healthy People 2020  Higher quality of life  Elimination of disparities and improved health overall 4  Environments that promote good health  Health development and behaviors Financing and Reimbursement Methods Eligibility  Medicare – over the age of 65, disabled persons entitled to Social Security benefits, person with permanent kidney failure  Medicaid – each state has its own specific criteria, but basically low- income elderly, the blind, disabled receiving Supplementary Security Income (SSI), and certain pregnant women  CHIP – children in low-income families that are uninsured Medicare Part A  Covers: Hospitalization, skilled nursing facility, home health care, hospice  Enrollee pays a premium and a sometimes a copay, government pays majority Part B  Supplemental insurance  Covers: physician visits, ambulance, outpatient rehabilitation, wellness exams, necessary preventive services  Income based premiums, annual deductible, 80:20 co-payments (most of the time) Part C  “Medicare Advantage”  Managed health care plan  Includes all of Medicare A, B, and D  30% of Medicare enrollees have Medicare Advantage Part D  Prescription drug coverage  Voluntary plan  Premium and annual deductible Medicaid  Financed through the state AND federal government  State decides the specifics such as criteria to receive benefits  Income and bank accounts are considered when deciding eligibility in different states Financing Pros Cons Necessary for some who can’t afford Could be paying more than it is health care worth Good for unexpected major medical Paying for insurance someone never problems uses 5 Risk Principles Risk – possibility of considerable financial loss risk is unpredictable risk can be transferred from the individual to the group losses are shared Cost Sharing  Cost sharing makes sure that the individual insured assumes at least some of the risk  (this includes premiums, deductibles, and copays) Private Insurance Group insurance – obtained through an organization, anticipates they a large number of people will get insurance through their sponsor Self-insurance – employers budget in possible medical expenses for employees instead of going through an insurer Individual private insurance – individually purchased, private health care (lots of people have this) Managed care plans – HMOs and PPOs, premium = they assume the risk for you High-deductible health plans – low premium costs, link the savings account to the HDHP, gives consumers more control Methods of Reimbursement Fee for service  Based on the assumption that services are set, identifiable, and individually distinct Package pricing  Multiple services included in one price Managed care methods  Variation of fee-for-service  Capitation – provider paid a set fee for the month per enrollee no matter what Medicare and resource-based relative value scale  Reimburses physicians based on value assigned to service Retrospective reimbursement  Rates set after assessing costs from previous year Prospective reimbursement  Uses pre-established criteria and determines reimbursement amount in advance Diagnosis related groups For hospital inpatient services with predetermined rates and bundled prices based on the diagnosis 6 Resource utilization groups Determine severity of health condition rather than just setting a fixed amount Case mix – the collective of clinical severity in a facility Ambulatory payment classifications Outpatient services for procedures Rates adjusted based on geographic differences in salaries Home health resource group Goes by a 60-day episode of care Predetermined rate for each episode Managed Care Provides health care services where an individual organization manages it  Financing – fixed premium that includes all services discussed in the contract  Insurance – is like an insurance company, takes responsibility if things wind up costing more  Delivery – MCO arranges health care for enrollee, independent providers, some even have their own physicians  Payment – capitation, discounted fees, and salaries HMO act of 1973 – alternative to fee-for-service, provided federal funds, wanted to increase efficiency MCOs were different because they had variations in payment PPOs used discounted fees instead of capitation Medicaid Managed Care Many Medicaid patients were enrolled in MCOs causing a fast increase in in managed care Medicare Managed Care (Medicare Advantage) Voluntary Medicare Advantaged plans doubled from 2005-2013 Utilization control methods in managed care 3 main approaches:  Expert evaluations of what is necessary  Determine how services can be provided at the least amount of cost  Review care and changes in the patient Types of Managed Care Plans HMO PPO POS Focuses on wellness care Provides services to Use prospective High out of pocket maintain health as well utilization costs 7 as regular medical care Do not usually have Allowed to go outside Allowed to go outside annual deductibles of network for providers of network for providers Patients can only use No referral needed for No referral needed for providers within specialist specialist network Specialty visits must No gatekeeping Capitation and fee for have a referral service Gatekeeping Providers paid through Some risk sharing discounted fee schedules Uses mostly capitation No risk sharing Risk sharing with provides Physicians and Other Health Professionals Future – there are too many people going into specialty fields and not enough general doctors. Therefore, eventually the demand for general physicians will exceed the supply MDs vs DOs Doctor of Medicine (MD) Doctor of Osteopathic Medicine (DO) Emphasizes the problem area of Emphasizes person as a whole patient Focuses on medical treatment Focuses on preventive medicine (diet, environment) Allopathic medicine Holistic approach Generalists and Specialists Most Dos are generalists and most MDs are specialists  Generalists take care of the whole patient altogether and focus much more on preventive medicine  Specialists take care of specific problem patient came to see them and focus more on the medical treatment of that particular problem Generalists include – family medicine, internal medicine, and pediatrics Specialists tend to be more popular as a profession because they make more money $$$  Primary care students – need to be familiar with a variety of patient conditions 8  Specialty students – focus more on inpatient hospital studies with technology and surgeries Non-physician Practitioners  Primary care dominant  Receive less advance training than physicians  Typically spend more time with patients than the physicians  Do not have a medical degree Outpatient and Primary Care Reason for growth  New technology has allowed many inpatient services to be  done for outpatients  Procedures are less intense and have less recovery time  Payers such as insurance companies aren’t fond of inpatient hospital stays  People like being home and receiving their health care in their home where it is more comfortable Key elements of primary care  Primary care is the first level of contact  Easier to access than specialty care and is less expensive  People have one specific doctor or group of doctors looking after them and know them o Benefits of primary care  Lower death rates (more preventive services)  People are less likely to go to the hospital  Overall better health and healthier choices Domains of Primary Care (also see week 5 notes and pages178-181)  Point of entry  Essential care  Community based  Integrated care  Coordination of care  Accountability Primaryy Secondary a ry Tertiaryy • routine • exp ert • h igh ly and specialis specializ b asic t ed h ealth consults h ealth care care (exp ensi ve) Outpatient Hospice  For terminally ill patients who have less than 6 months to live  End-of-life care  Focuses on medical, psychological, and social services  Primary emphasis on pain and symptom management and psychosocial and spiritual support Outpatient long term care  Generally associated with nursing homes, but there are other settings  Two types of LTC services: case management and adult day care  Purpose is to provide appropriate setting to meet a patient’s health care needs Good Luck Everybody!


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