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- Enrollment in greater numbers by high-risk individuals compared to those who are healthy -
- Premiums rise for everyone, making health insurance less affordable unless healthy individuals are mandated to buy health insurance
Clinical information system:
3. examples (2)
- involve the organized processing storage and retrieval of information to support patient care delivery
- benefits: increases efficiency, decreases errors
- drawback: only 5% of hospital actually use it
- 1. EMR
- 2. computerized physican order
- elegibility determined by category membership to a group
- medicaid "categorically needy"
4 main assumptions
- evaluate benefits in relations to cost (both are expressed in dollars)
- 4 main assumptions:
- 1. problem or health condition CAN be ID or diagnosed
- 2. problem can be controlled or eradictated
- 3. benefit or outcome can be assigned a dollar value
- 4. cost of intervention can be determined in dollars.
- **Equates 1 year of quality life to $100K
examples of strategies ( 5)
strategies used to control utilization and cost of health services
- 1. restricting financing for health insurance v. unresistred extension to uninsuranced
- 2. reducing reimbursement to providers
- 3. rationing technology
- 4. focus on primary and preventive care to control costs of specialized care- managed care
- 5. utilization caps
1. it is a ....
2. formuala for cost expenditures
3. practiced by...
- --a form of financing
- --E = P (payment) times Q (expenditures)
- --practiced by insurance companies, government
a practice to....
2. example of the practice (3)
a practice to protect providers against the threat of litigation
- 1. prescribe diagnostic tests
- 2. return check up visits
- 3. retain lots of documentation
- disadvantages: unneccesary? costly, and inefficient
book- excessive medical test and procedures performed as protection agains malpractice lawsuits otherwise regarded as unnecessary
first-dollar coverage programs
- = Cost Sharing
- plans without deductibles and copayments
- almost nonexistent
is a plan which...
no relationship b/w...
- provides reimbursement to the insured, without regard to the expenses actually incurred
- no relationship between the provider and the insurer
- payment: the insurer gives a predetermined amount to the beneficiary for services (balance becomes an out-of-pocket expense)
- is the imbalance in the distribution of health professionals needed to maintain the health status of a given population at an optimal level
- 1. (geographic)- surplus in some regions and shortages in inner city and rural
- 2. speciality maldistribution (due to tech, reimbursement, and specialty oriented training)
- large number of buyers sellers
- free market in health care requires an effective health care insurance market but the market is imperfect/inefficient
- causes of market failure:
- Moral hazard
- adverse selection
- assymettry of info(take care of us and profit?)
- supplier induced demand- liscensing for doctors limited
- imperfect competition (monopolies)
is a decision for coverage on which elegibility depends on income (pre-determined income levels)
- disadvantage- stigmitizing elderly as low income
- examples: medicaid
Medicare and Medicaid
- Social Security Act (SSA)
- 1965 -care
- title 19
- insures indigent 17% (poor or needy--not all poor people) for those that eligibility (means test)
- financed: Joint- fed (matches) and state program- (financed by Fmap-(50-83% of medicaid cost depending on state
- government is insurer and payer)
Automatically insured under medicaid
- 1. family with children-recieving support under the temporary assitance for needy families (TANF)
- 2. citizens
- 3. supplementary security income (elderly, blind, disabled with low income
- 4. children and pregnant women at or below 133% of FPL
- 5. Medically needy-determined by states (institutionalized in nursing or psychiatric services, recieving community-based services (would be recieving better care if could)
Services offered under medicaid (11)
- 1. inpatient outpatient
- 2. Physician FQHC (fed qual health centers)
- 3. rural health clinics
- 4. outpatient labs and services
- 5. nursing facilities for 21 and up
- 6. homehealth
- 7. pediatric and family/nurse
- 8. midwives
- 9. medically and surgical dentist services
- 10. preventive diagnosis and treatment services (vacc)
- 11. family planning
- 12. pregnancy related services
% Medicaid Eligible Who are Not Enrolled
financed by: ???
- title 18
- elderly-12% of population (65+), disabled and people with end-stage renal disease
- operated by CMS (centers for medicare and medicaid services-branch of DHHS)
- benefits: no class distinction & uniform
- national standards for eligibility and benefits
parts of medicare (4)
- A-hospital (benefit period (amt inpatient care) -deductible)
- B-supplementary medical insurance-voluntary program finached partially by tax revenues and premuims
- C-Medicare Advantage-additional choices of health plans (1987) -managed care
- D-prescription drug coverage (2006)
medical arms race (see week 5 slides)
- refers to competition in medical technology which creates demand for more services
- competition actually drives costs up (whereas normally drives costs down) because we recruit specialists
payers could see overuse of higher priced technologies and procedures because of excess capacity.
A popular term for escalating health care costs due to proliferation of expensive medical technology and devicesconsequence:led to the trend of hospitals expanding into targeted geographic markets to capture well-insured patientsKey tactics:include building full-servicestate-of-the-art hospitalsestablishing freestanding emergency departments and other outpatient servicesacquiring physician practicesoperating medical transport systems to shore up a referral base and increase the number of inpatient admissions
- consumer behavior that leads to a higher utilization of healthcare services when the services are covered by insurance
- people dont bare the burden of the actual costs for their health care choices
national health expenditure
of the amount the nation spends for all health services and supplies, public health services, health related research, administration costs, and investment in structures and equipment during calender year
- book def... conceptualized from a macro perspective
- a widely used measure is the propotion of the GDP a country spends on the delivery of health care services. –from a micro perspective-health care expenditures refer to costs incurred by employers to purchase health insurance and out-o-pocket costs incurred by individuals when they receive health care services.
- quad-function model- Canada
- financed- gover taxes
- delivery- private provider (dettached)
- requires: tighter consolidation of insuracne and payment functions
- under section 501-c3
- tax exempt from federal, state and local taxes (income, proprty and sales)
- GET tax-apply seperate exemption
- they sub for phyisians in (some) primary care activities
- often consult physicians
- founded in 1960s due to lack of primary care in rural areas where there was a lack of access.
- NPP, NP, PA, CNM
- mid-level providers (dont have to have MD)
can be purchased by self-employers from private insurance to protect against the potenital risk of high loss.
- Reinsurance essentially is insurance for insurance companies (and, sometimes, for other organizations that face risk, such as employers that self-insure their employees' health care costs).
- not activated until a deductible is met
- there is a "ceiling," or upper limit, on reinsurable expenses.
- have coinsurance rates (amounts that the policyholder must pay for particular services) that apply to expenses between the deductible and ceiling.
providing protection to insurers for the risk of extraordinarily high costs incurred by any individual,
insurers do not have to build such reserves into their premiums, which can thus be lower.
- financing- tax support
- delivery-government manages infrastructure (and operates institutions)
- providers: goverment employees or tightly organized
- defined public good (service education or comm welfare)
- ex great brit
- National health care system
- Providers bill government and they pay
- Cost-containment efforts in entire health care system require major overhaul.
- ex. China
social health insurance system
- Goverment mandated
- Contribution by employers and employees
- delivery: private
- financing: insurance and payment is closely integrated and coordinated
- payment: 3rd party-private non-profits "sickness funds"- are responsible for collecting contributions and paying physicans in hospitals
- created by the provider
- and is anything the provider does to encourage and create need for more medical services (more than necessary)
In a free market situation where the doctor is primarily motivated by the profit motive, the possibility exists for doctors to exploit patients by advising more treatment to be purchased than is necessary
a result of:
it is the...
occurs quickly when:
- a result of technology diffusion (spread of technology once developed)
- desire to have state-of-the-art technology available and to use it, despite cost or established health benefits
- occurs quicky when percieved benefit, matches values and needs, 3rd party payment
–US versus other countries