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Healthcare Systems Midterm


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fixed payment to HCP per member per month
moral hazard
having insurance means we consume more than we would if paying out of pocket
national health insurance
financed by gov't, delivered privately, i.e. canada
national health system
financed and delivered by gov't, i.e. great britain
socialized health insurance
financed through gov't via mandatory employer/ee contributions, private delivery, sickness funds, i.e. germany
quantity of healthcare consumed
demand-side rationing
production of healthcare depends on consumers' willingness and ability to pay; market justice
it's individual's duty to do what's right; ignores societal responsibility
market justice
1. emphaisis on individual
2. healthcare is distributed through supply-demand,
3. based on ability/willingness to pay, 4. no gov't interference
social justice
1. healthcare distributed by gov't
2. societal responsibility
3. need based rather than ability to pay
greatest good for the greatest number; ignores the individual
6 payers in the healthcare system
Commercial companies
3 things that shape today's economics of healthcare
uniformed consumer
perverse incentives
4 ways technology has an impact
3 major health indicators
life expectancy at birth
life expectacy at age 65
infant mortality
5 challenges to US healthcare system
1. no central agency
2. access based on coverage
3. imperfect market
4. multiple 3rd parties
5. legal risks influence practice
community rating=
premium is based on utilization in geographic region- healthy people pay for sick people
experience rating=
premium based on demographics or experiences
Blue Cross/Blue shield: which is hospital and which is physician
BC- hospital
BS- physician
key differences between non-profit and for profit
Non Profit: governed by community boards, owned by the community, tax exempt
For Profit: has shareholders, excess revenue beyond expenses doesn't have to go back to institution.
who finances/operates medicaid?
financed by federal and state, operated by state
who finances/operates medicare
federal for both
who's eligible for medicare
>65 y.o
who's eligible for medicaid
below the poverty level- $9800 individual or $20,000 for family of 4
what year were medicare and medicaid established
What does part A medicare cover?
hospital expenses, no nursing home coverage
who pays for Medicare part A
it's included for free- automatic coverage
what does MEdicare part B cover
supplementary- physician, outpatient, DME
who pays for part B
Medicare pays 80% of "assigned" rate and pt. pays 20%
what is assignment
docs agree to a predetermined rate set by medicare- which may be lower than the going rate
What does medicare part c (Medicare + choice) cover?
MCO participation
who pays for part c?
Medicare pays 95% of the community rating; only for very healthy elderly people
what does part d cover?
do medicaid participants pay a premium?
what is managed care?
insurers and providers collaborate to use financial incentives to alter provider/patient behavior to lower costs and increase effectiveness
what is retrospective payment
provider receives a payment after services have been provided
what is prospective payment
provider recieves payment before-hand, regardless of services rendered
which type of payment offers incentive for providers to keep pts healthy
with capitation, who does the risk lie with
3 keys to success with MCOs
1. hospital stays
2. ER usage
3. specialists
3 types of cost-sharing
what is stop loss provision
the maximum out of pocket liability an insured person pays in a given year
What are the types of MCO's?
whats the most common type of MCO
what distinguishes HMOs from other types
wellness care, capitation, and using in-network providers
describe the staff model HMO
an HMO employs its own fixed salaried docs, i.e. puget sound
describe group model HMO
HMO contracts with multi-specialty group practices to provide comprehensive services, i.e. Kaiser
describe network model HMO
HMO contracts with more than one medical group practice, i.e. Health Insurance Greater NY
describe Independent model HMO
independent docs form groups that contract with HMOs
which model of HMOs is most common
what's the relationship between choice, cost and provider control
the more choice, the higher the cost, and the less provider control
distinguising features of PPOs
can pay higher fee for out of network providers if you want, and arrange discounted fees with providers rather than capitation
What is a POS plan?
a hybrid of a PPO and HMO- free choice of providers, increased out of pocket costs, and tighter utilization
3 key measures of health care
access, quality and cost
what are barriers to access
1. Financial- lack of insurance
2. Structural- shortage of doctors, needing referrals,etc.
3. Personal- religious, cultural
what is the 10/90 gap
10% of the worlds population uses 90% of all healthcare resources
what are key indicators to look at when comparing healthcare systems
-population health
-system responsiveness
-distribution of responsiveness
-distribution of financial burden
what are the 4 varieties of healthcare financing globally
-out of pocket
-individual private insurance
-employment based private insurance
financing in Germany
govt' mandated, employment based private
delivery in Germany
mostly private
financing in Canada
delivery in Canada
mostly private
financing in UK
delivery in UK
financing in Japan
gov't, some employee contributions
delivery in JApan
mostly private

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