PBH-ch.10 and 11

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Author:
MelodyRodsuwan
ID:
165380
Filename:
PBH-ch.10 and 11
Updated:
2012-08-09 09:42:14
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PBH 10 11
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PBH-ch.10 and 11
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  1. framework for healthcare
    • access 
    • providers
    • stay healthy 
    • get better
    • living with the illness
  2. electronic health records****
    • improve safety
    • effective and efficient
    • help management
  3. us health care cost
    • 2.5 trillion
    • 17% GDP
  4. Tricare
    Military 
  5. Medicare
    • hospital/doctor
    • part of prescription 
    • preventative services
    • nursing and rehab
    • THRU PAYROLL TAX 1.45/1.45
  6. Part A
    • Hospital, nursing, home, hospice care
    • 1000deductible
    • Payroll tax then no hospice care, but no premium required
  7. Part B
    • Voluntary supplementary insurance 
    • Diagnostic and therapeutic/outpatient
    • 75tax/25premium
    • 20copay is covered by medigap policies
  8. Part C
    Prepaid health plans
  9. Part D
    • New prescription plan
    • Note: must have A and B
    • Premium and deductible
    • 75 up 2500 per year
  10. do-nut hole
    above the 2500 limit; no coverage
  11. catastrophic level
    95 covered when hits to 5000
  12. Not covered by Medicare
    • Nursing home care 
    • Custodial care
  13. Medicaid
    • federal plus state program for the poor 
    • largest source of funds for nursing homes
    • custodial care
    • inpatient, outpatient, preventive
  14. federal medicaid
    50-83% depending on the per capita income of state
  15. states medicaid
    • only if family income is less than federal poverty level 
    • disable, children, pregnant women
  16. SCHIP
    • longer periods of eligibility
    • Nowtax on cigs
  17. community rating
    • based on regardless of health status of the individual
    • Social Justice
  18. NOW experience rating
    • based on groups' use of services
    • Market Justice
  19. fee for service
    • a la cart, spec services
    • overuse of services which can lead to increasing health care costs
  20. Preferred Provider Plan
    • patients can stray from the provides but they would have to pay moree
    • From fee for service
  21. Health Maintenance Organization
    • fixed based/monthly fee package on enrolled members no matter how many number of services aka capitation 
    • UNDERUSE
    • preventive services are a good thing though
  22. Point of Service
    • origin HMO
    • use more out of pocket/care outside
    • Mixed models
    • most common
  23. uninsured
    • healthy, young
    • not qualifited
    • self-employed
  24. to increase health care***
    • aging population
    • technology
    • success have raised expectations
  25. to control the costs***
    • reimbursement
    • cost sharing
    • regulation
    • malpractice restrictions
    • competition
  26. reimbusement incentives
    • reduced hospital stays
    • restrict on inpatient event
  27. cost sharing
    cost to individual
  28. regulation
    • medicare and medicaid
    • politically now
  29. malpractice restrictions
    • change defensive medicine
    • reduce the amnt of ppl sueing/lawsuits
  30. competition
    • the purchaser is informed
    • purchasing power
    • multiple providers
    • negotiate
  31. affordable care act: insurance can't
    • deny to kids with pre existing like asthma
    • have lifetime limts on benefits like cancer
    • cancel w/o proving fraud
    • deny lcaims without a chance for appeal
  32. affordable care act: consumers can
    • get cost free preventive services
    • teens on parent's plan til 26
    • can choose doctor
    • can use ER without penalty
    • cheaper drugs for seniors
    • 80/20 rule
  33. inpatient
    • at least 24hrs
    • hospitals and nursing homes
  34. outpatient 
    • less than 24hrs
    • clinics 
  35. healthcare system 
    delivery and financial 
  36. health care delivery system 
    defined population by linkage of inst
  37. health systems
    public health and health care
  38. medically underserved area vs. population 
    no resources vs. limited access b/c of barriers 
  39. community health center
    • bypassing state govt
    • health centers conslidation act '96: combined with migrants and homeless
    • need to facilitate access to care
    • governing borad 
  40. medical malpractice 
    • civil law its decided by jury based on "majority of evidence" 
    • build on negligence law: to protect 
  41. cap
    limit of insurance will pay 
  42. copayment
    the insured needs to pay 
  43. deductible 
    before eligible you pay 
  44. to eligable medicaid
    income level 
  45. to eligible medicare
    age and enroll in SS 
  46. premium
    price paid in monthly/yearly
  47. how many nursing homes
    16,000
  48. measures healthcare assessed
    • structures
    • process
    • outcome
  49. single payer
    govt takes costs on indiv
  50. individual mandate
    govt reimburse or rich tax exempt
  51. National Committee for Quality Assurance
    • measure quality
    • access and service
    • qualified
    • stay health, get better, live with illness
  52. capitation
    fixed number per month regardless number of services
  53. prox cause
     what whould happen if neg didn't occur
  54. criteria of malpractice
    • to care
    • to have standard
    • to cause injrugy
    • direct, indirect, punitive damages
  55. financial hopsital
    • 90% of 5000 are nonprofit
    • half of 5000 are private nonprofit
    • 20% of 5000 are state
  56. hospicd
    6months or fewer to live
  57. coordination
    • clinician and patient
    • inst
    • financial
    • health care and pbh
  58. kaiser
    fixed monthly fee
  59. veterans
    med school for education/research
  60. covered service
    insurance will pay
  61. customary prevailing and reasonable
    balance billing
  62. med loss ration
    ratio of beneift payments paid: premiums collect
  63. portability
    insurance after leave job

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