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UF / History / ART 3111 / What is the health maintenance organization act of 1973 all about?

What is the health maintenance organization act of 1973 all about?

What is the health maintenance organization act of 1973 all about?


midterm exam Review

What is the health maintenance organization act of 1973 all about?

major characteristics of the u.s. Healthcare system -no central governing agency, little integration - technology driven delivery, acute care focused - high in cost, unequal in access, average outcome - delivery of healthcare underperfect market - government as subsidary to private sector - fusion of market and social justice - multiple players and balance of power - legal risks influence practice behavior - access to services based on coverage

The flexnor report (1910) is published by who?

Don't forget about the age old question of Discuss two traditions in which dance plays a role in religion. describe the dance styles and how they relate to religious beliefs.
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2. A. Managed care: basic functions of health care delivery,

employs mechanisms to control utilization & costs of medical services. - Military healthcare system : Tricare, V.A. healthcare system - Subsystems for special populations: Medicare (elderly, disabled, end

What are the major characteristics of the us healthcare system?

stage renal disease), & Medicaid (low income adults, children, elderly & disabled). - Integrated systems: network of healthcare providers and organi zahons that provides a coordinated continum of services to a defined population and is willing to be held fiscally and clinically responsible for outcomes. In 2 - long term care delivery medical and nomedical care provided to individuals who have chronic health issues that prevent ADL. (assisted living facilities, nursing homes) medicare does not cover LTC, medicaid covers certain levels. We also discuss several other topics like What is succinylcholine?
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public health system improve and protect community health through monitoring, diagnosing informing, educating and more.


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J.A.U.S. healthcare safety net serves: We also discuss several other topics like Who founded the first california mission?

medicare: serves elderly, disabled, and end stage renal disease. Medicaid: serves low income adults, children (CHIP), elderly

and dicabled. -medicaid serves more people, population is higher among If you want to learn more check out What are the three types of tales in canterbury tales?

below 65 age. B. other vulnerable populations include minority groups,

certain immigration states, or geographically & economically disadvantaged.


Historical context of Health care Delivery in the u.s. T. (Table 1.1) u.s is a pluralistic health care system om

canada and united kingdom have a national system, and germany has a socialized system. Canada, the government finances health care through general taxes,

germany finances health care through government mandated contributions by employer temployee, both provide healthcare through private providers. Uk, the government manages the infrastructure, and finances a tax supported program, healthcare is provided by government.

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Forerunners for todays hospitals were moshua at boorhouse) alms house : vun by local government, confined indignant - asylum: state government yun, untreatable chronic mental illness. Berthouse local government run to isolate people who

tracted contagious disease. Main purpose was to contain spread of communicable disease. ni

saries outpatient clinic to provide free care


to pay, as we

those who can't afford

o cant afford to pay, as well as provide in


- dispensaries: Outpatient clini


drugs to


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Historical context of Health Care Delivery in the us. 3.A medical training until 1870 was recieved through

apprenticeship with a practicing physician. Post 1870, medical schools were formed by american physicians to supplement income, Standards were low and resources lacking. In practice, physicians relied on sences rather than training, knowledge because medicine was so primitiven


B. Flexnor Report (1910) published by Abraham Flexner

discovered widespread inconsistencies in medical schools, closed any school that did not formalize education standards or accredit through the AMA.


4. A. Medicare A+B formed in labs, part A used social

secunty funds to finance hospital insurance and short

term nursing home coverage. Part 13 covered physicians bills through government-subsidized insurance medicaid (1965) covered low income persons, financed through federas matched funds according to per state capita income. B. Private health insurance · began as form of disability coverage during temporary disability. In 1929, Justin F. Kimball formed a hospital insurance for teachers at Baylon University Hospital. Within years, it became a model for all BCBS plans.

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5. Hmo movement began in 1973 with the Hmo Act of 1973

to prevent escalating health care expenditures and provide o an alternative to fee-for- service practice of medicine


1. medico


Health Beliefs & Values Americans view health on conservative principles that focus on market justice, with some social justice principles. Americans value independence and little to no government control, therefore market justice fits well. Technology affects health care by improving quality and outreach tactics.

2. medical model health is defined as absence of illness or disease.

Social /alternative model> health is a state of optimal

Capacity of an individual to perform his or her social roles and tasks to holistic medicines treat the individual as a whole person, incorporates the spiritual dimension as a fourth element in

addition to physical, mental, and social aspects. 3. Social determinants of health demographics, socioeconomic

stahes, personal behavior, community level inequalities medical determinants of health preventitative care primary

Care, general health status, long term care is spa I public policy interventions product safety regulations,

Screening food and water sources, enforcing safe work environments Community based interventions: nutrition programs, community based partnerships, culturally approphate care nu s e Health Care System Interventions: inteq Taled electronic medical records

individual level interventions: allening individual health astening behaviors 5. market iustice: benefits distributed on the basis of peoples. willingness and ability to pay. tice: eauitable

distribution of h equitable justice social distribution of healthcare is




social responsibility. 6. health determinants are 7. attaining high quality, longer living lives, achieving health equity

land eliminating disparities, creating health promoting social and physical environments, promoting quality of life. ?page 42)

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Financing and Reimbursement methods 1. medicare: 65 or older disabled and entitled to ss, end stage

renal disease medicaid: means-tested program, typically low income elderly, Iblind, disabled recieving ssI and some pregnant women. CHIP children of low income families whose family income

exceeds medicaid threshold; some pregnant women, parents and caretakers are covered.

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Medicare Part 1 : hospitalization, short term rehabilitation in a skilled nursing facility sedonte

Part B physician, ambulance, outpatient rehabilitation, annual wellness exam, preventative services, outpatient services, limited home health services not associated with a hospital stay Part C: Medicare managed Care / advantage: way to redeve all Part Al Part / Part D through an mco. This eliminates the gap of Medigap coverage

Part D: prescription drug coverage ® Part Ai Special payroll taxes paid equally by employers & employce

Part Bi general tax revenues', required premimum contributions Part C: general revenue, Payroll taxes, beneficiary premiums

Part D general revenue, payroll taxes beneficiary premiums must be enrolled in part itt Part B , must pay part 1

premiums and an additional premium to the managed care organization and added to medicare under oct of 2003, available to anyone regardless of income who has coverage under part A & B. Medicare advantage prescription drug plans. are available to those who want to obtain services.

through Mcos participating in part c. © Medicare advantage: 30% Standard : 70°C


3. medicaid A. financed by federal state government, federal government

provides matching funds to states based on per capita w income in each state eligibility varies from state to. State and for a state to recieve federal matching funds.

the state must provide some specific health services. B. each state manages its own medicaid program na C. eligibility criteria, covered senices, and payments to providers

vary state to state.

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4. desirable effects of financing: enables access to healthcare

technology and seniles with liberal reimbursement proliferate Undesirable effects of healthcare: payment to provideis, moral hazards, provider induced demand

5. - Risk is unpredictable for the individual insured

- Risk can be predicted reasonably for a group / population - Insurance provides a way to transfer nisk from the individual to

group through pooled resources so - achial losses are shared on some equitable basis by all group members

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6. cost sharing

premium cost sharing: insured workers pay a share of cost of

premiums n suste deductible: insured pays annually before any benefits by the plan are payable. as Ico payment out of pocket ree each insured pays every time health senices are recieved after deductible has been paid.

Financing and Reimbursement methods 7. - group insurance: obtained through organization such as

an employer, union or professional organization - self insurance: large emplovers assume nisk by budgeting

tunds to pay medical claims incurred by employees. -individual private insurance: non-group, purchased

Independently vie managed care plans: assume risk in exchange for a premium

Hmo & PPO - high deductible health plan: uses savings plan to pay health care Costs, gives insured more control, low premium cost.



8. A. Fee for Senice: Charges set by providers, insurers passively o paid claims.

B. bundled payments number of related senices included in one price c.mcos-Capitation provider is paid set per monthly fee per insured, regardless of whether provider is seen on how often. discounted fees, afler senice is rendered, provider bills Mlo seperately. D. Medicare reimburses physicians according to value assigned to each senice E: Medicare and retrospective reimbursement: rates are set after evaluating per diem rates & F: Medicare and prospective reimbursement: uses pre established criteria to determine in advance the amount of reimbursement. 1.diagnostic related groups: predetermined rate setaccording to DRG according to principal diagnosis at time of admission. 11. Resource utilization groups: categories used to determine a skilled nursing facilities overall severity of health conditions requiring intervention. lll. ambulatory payment classification associated with medicare's outpatient pro Spective payment system (Opps): divides all outpatient senices into more than 300 procedural groups.

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8. 10. resource utilization groups: aggregate

severity is determined by case mix. V. Home health resource groups all serices provided by a home health care agency are bundled under one

payment made on a per patient basis. OASIS loutcomes and assesments information set) used to rate each. patients status, translates into points used to determine


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Managed Care - Financing: negotiating premiums between employers and

mco. - Insurance inco collects premiums for Insuring groups of

enrollees, takes financial responsibility if total costs of senices exceeds fixed premium revenue. - Delivery MCO arranges to provide healthcare to enrollees. - payment mcos use capitation, discounted fees and

salaries for payment. shantos A MLOs arrange to provide care and accepts payment differently

than conventional insurance..


2. The Health Maintence organization Act of 1973 was passed in

order to address concerns of escalating health expenditures, it provided an alternative to fee-for-senice payment. Stimulated

growth of tumos by providing federal funds to establish new Hmos. PPOs were created in reaction to competition between mcos. these used discounted fee payments instead of capitation


managed Care

al cald managed care enrollees have the choice to enoll in a managed care plan under ma program, or remain in traditional fee-for-servce.

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4. Medicaid enrollment: Balanced Budget Act of 1997 gave

States authority to implement mandatory managed care enrollments without federal waivers.

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utilization control methods in managed care: - expert evaluation of which senices are medically neccessary - determining how senices can be rendered most affordably without sacriticing quality.n et - review of process of care and changes in patient condition

to revise care it applicable a - gatekeeping requires primary cave physician to

Coordinate all healthcare services needed by an ennilee. -utilization review, evaluating appropriateness of services

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6. A. Hmos: use of only in network providers permitted in a

focus on prevention & primary care, gatekeeping used t rang 1 Providers paid under capitation mostly, some fee for service as risk sharing with providers under capitation s o ng an


B. PPOS in network and out of network providers permitted no gatekeeping, contracted providers only, no restricted access

to specialty care. Providers paid according to discounted fees, no risk sharing som


c. Pos: in network and out of hetwork permitted, contract providers only unrestricted specialty access, combination of capitation & fee for service

some list Sharing

Physicians and other Health Professionals The healthcare sector will continue to grow due to growth in overall population, and aging of the Population as baby boomers turn 65, and increased life expectancies.

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2. Physicians

A. mas vs DOS -MDS are trained in allopathic medicine, active intervention to produce counter acting reaction to attempt to heutralize disease affects. - Dos practice osteopathic medicine, where they emphasize the musculoskeletas system and stress

preventative medicine and an B. specialists vs generalists do - specialists are typically mos; deal with particular disease or organ systems. se - generalists are typically Do si deal with preventative

senices and less Severe problems. 1. generalists include: pnmary care physcians, family medicine

or general practice, internal medicine.no 11. specialists are more common due to better pay, more prestige

and more technology a II. pn mary care physicians are trained in ambulatory care settings

becoming familiar with a large scope, Specialty students spend time in inpatient hospitals where they are exposed

to state of the art technology to define and treat disease. c. 2013-767, 100 physicians practing under 75, 31% women 3. less training than physicians, but more than kils,



access to primary care, establish better rapport with

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Outpatient and Primary Care stare 1.- reimbursement costs less than impatient care. As a - technological factors minimally invasive procedures de

and short-acting anesthetics make surgical procedures less. traumatic and short recovery times. stoon utilization control factors inpatient hospitalization

strongly discouraged by various payers. - -social factors most patients do not want to be

Institutionalized unless absolutely neccessary tood og

2. Primary Care is distinguished by duration, frequency, and

level of intensity. Non

-3. Primary care benefits include: decrease in disease and

morbidity, total lower health care costs.al

4. ambulatory care consists of diagnostic and therapeutic

services, but not all ambulatory care patients ambulate to; LED may arrive by land or ain).




5. Domains of primary care

Point of entry community based coordination of care essential care integrated care accountability


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