S&S Chapter 1
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Why does cost containment remain an elusive goal of the US Health Service delivery?
- 1) US Health System is not controlled by a central agency.
- 2) No global budgets or rationing of utilizations and resources.
- 3) Private systems of finance and delivery
- a. Private finance=54%2
- b. Government Finance=46%
- 4) Government does formulate Standards of Participation through health policy/regulations
What are the two main objectives of a HCdelivery system?
- 1) It must enable all citizens to obtain HC services when needed.
- 2) Services must be cost-effective and meet certain standards of quality.
Four basic components of US HC delivery system?
- 1) Finance - most privately insured patients are sponsored through their employer, as a fringe benefit. Most companies purchase insurance through an MCO
- 2) Insurance - MCO specifies how/where an individual can receive care. Also act as a claims processor and manage the disbursements of funds to providers.
- 3) Delivery - refers to the provision of HC providers. Providers refer to any entity that delivers HC services and can either independently bill for those services or is tax supported.
- 4) Payment - deals with reimbursement for services delivered. Insurer determines the amount paid for certain services. Funds for actual disbursement comes from the premiums paid to the MCO. In government insurance plans, tax revenues are used to pay providers.
Why is it despite public and government healthinsurance programs, some citizens are uninsured?
- US has an employer-based health plan
- In most states, employers are not mandated to provide HI to employees.
- Employers who offer HI, it’s not mandatory that all employees participate.
What is Managed Care?
Insurance providers who use a system to integrate the functions of financing, insurance, delivery, and payment. Also use mechanisms to control costs and utilization of services.
Why is the US HC market referred to asimperfect?
The US HC system doesn’t pass the basic test of a free market, where prices are decided upon by payer(patients) and providers. Thus, the system is considered a quasi-market or imperfect market.
Discuss the intermediary role of insurance inthe delivery of HC.
An intermediary should integrate the four basicfunctions of (Finance, Insurance, Delivery and Payment) of HC system in orderto achieve efficiencies and control costs and utilizations of HC services.
The intermediary role of insurance also creates a wall of separation between the finance/delivery functionsso that quality of care often remains a secondary concern.
What main roles does the government play in theHC system?
Government tries to maintain/enhance existing benefits for select population groups and simultaneously tries to reduce costs of providing these benefits.
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