exam 4: health care economics

Donut Hole

A gap in medical coverage under Medicare Part D, where beneficiaries enrolled in Part D plans pay 100% of their prescription drug costs after their total drug spending exceeds an initial coverage limit until they qualify for catastrophic coverage.

32%

ACA concerns; family premiums (employer-sponsored plans) have increased _______ in cost

limited

ACA concerns; insurer competition is ___________ or declining - now, 70% of US counties have only one or two insurers - when competition is absent, prices go up

MSA (medical savings account)

Alternative means of health care in which individuals make tax-deductible contributions to a special account that can be used to pay medical expenses. - this account. is emptied at the end of the year (does NOT roll over onto the next year) - shifting of responsibility, knowledge, and decision-making involvement to the individual receiving the care

determinants of health

Factors that contribute to a person's current state of health. - These factors may be biological, socioeconomic, psychosocial, behavioral, or social in nature. - biology/genetics: sex and age - individual behavior: alcohol use, injection drug use (needles), unprotected sex, smoking - social environment: discrimination, income, and gender - physical environment: where a person lives and crowding conditions - health services: access to quality health care and having or not having health insurance

federal

Medicare is not a shared program between the state and federal program, only the __________ government

health care rationing

Method to reduce health care costs by controlling the use of health care services and technologies. - reduced access to health care - potential decreases in acceptable quality of services offered - health care provider's refusal to accept Medicare or Medicaid clients

annual

Most public government agencies operate on an ____________ budget, and they plan for costs by estimating salaries, expenses, and costs of services for a year. - less nurses are being hired, and more health educators are hired instead

cost sharing

Provision of a healthcare that divides the cost of health care services between insurance companies and patients - includes co-payments and deductibles

private

Public health agencies, such as health departments and WIC programs, receive primary funding from taxes with additional money for select goods and services from __________ third-party payers.

public

Recent trends of third-party reimbursement indicate that the highest portion of third-party health care financing is being carried by combined _____________ sources

Essential Health Benefits (EHB)

Required uniform benefits that must be offered by the ACA that includes 10 major areas of coverage. everybody has to have this coverage, even if they do not need it 1. 1.Ambulatory patient services 2. Emergency services 3. Hospitalization 4. Maternity and newborn care (a lot of people do not need this) 5.Mental health and substance use disorder services, including behavioral health treatment 6 .Prescription drugs 7. Rehabilitative services and devices 8. Laboratory services 9. Preventive and wellness services and chronic disease management 10. Pediatric services, including oral and vision care

first; last

The United States ranks _______ for health care expenditure in the world, but ________ for coverage. - US ranks fifth globally for overall timeliness of care - US leads in cancer screening and survival, as well as heart disease management

human capital

The goal of primary prevention is to preserve and maximize ____________ ___________ by providing health promotion and social practices that result in less disease and reduce the burden of avoidable illness and disability

97%

_______ of health care dollars are spend on SECONDARY and TERTIARY prevention/care - the affordable care act had increased funding for primary prevention strategies and public health (shortly after this was passed, it was sequestered, and the money was moved elsewhere)

dual eligible

_________ _______________ beneficiaries are among the poorest and sickest beneficiaries covered by either program and consequently account for a disproportionate share of spending in both programs - individuals who qualify for medicare and medicaid (9.6 million)

health

____________ spending is outpacing gross domestic product - more than $17 of every $100 spend has been spent for health care

private

_____________ health funding includes... - out of pocket payments and charity - cost sharing - private insurance, managed care, individuals (medical savings, health savings) - employment based insurance - health insurance purchasing cooperatives - self insurance - access limitation

private

______________ health care payers have a premium competition leading to an increase in covered benefits - the health needs of high-risk populations led to the passage of Medicare and Medicaid legislation - Blue cross blue shield - employment-related - indemnity - HMO - PPO - cooperatives - retrospective and prospective reimbursement mechanisms

rationing

______________ of health care has always been a part of the US health system. this is determining the most appropriate use of health care/resources

physicians

_______________ are the health care system's main gatekeepers

capitated

_______________ reimbursement is prospective reimbursement for services where third-party payers determine amount that practitioners will be paid for a unit of care, before the service, placing a limit on the amount of reimbursement received per patient

challenges

_________________ for the twenty-first century - emergence of new and old communicable/infectious diseases - larger food-borne disease outbreaks - acts of terrorism - chronic disease prevention programs - infrastructure to support more complex technologies - hospital "internists" - more care provided in the home - doctorate of nursing practice (instead of masters) - emphasis on prevention and wellness - social and economic issues

barriers

_________________ to health care access; •Rising costs/inability to pay/insufficient financial support •Increased number of people covered by Medicare and Medicaid •Decreased number of people covered by private insurance •More employers offering insurance and fewer employees are purchasing it •Private insurance does not guarantee financial access to care •Public programs offer inadequate prenatal and mental health care programs •Negative outcomes for the uninsured and underinsured •Physical barriers •Structural inaccessibility, lack of appropriate equipment, or inability to communicate •Inequality in the distribution of services, transportation difficulty, conflict with work hours, and failure to provide services •Language barriers/difficulties and fear of reprisals

ACA (Affordable Care Act, 2010)

a bill that became a law as a result of a promise to the American public by President Obama that health care reform would occur as part of his presidential agenda. provisions include... • Quality, affordable health care for all Americans • A defined role of public programs • Improving the quality and efficiency of health care • Preventing chronic disease and improving public health • Health care workforce expansion • Transparency and program integrity • Improving access to innovative medical therapies • Community living assistance services and supports instead of nursing homes • Revenue provisions

public health finance

a growing field of science and practice that involves acquiring, managing, and using of money to improve the health of populations through disease prevention and health promotion strategies. - PRIMARY PREVENTION

PCP (primary care provider)

a lot of individuals who are uninsured/underinsured do not have access to a consistent ___________ - this is where the quality in health care is - poverty has detrimental effect on health - SES is inversely related to mortality and morbidity for almost every disease

public health economics

a science that focuses on producing, distributing, and consuming goods and services as related to public health - a much smaller science - people do not really pay attention to public health until it is too late (like COVID-19)

primary

a shift to _________________ prevention could result in a significant reduction in the staffing needs and profitability of the health care system, the largest employer in the US - shift in approach to Health care from reactionary, acute-care orientation toward a proactive, primary prevention orientation

understanding

access to health care includes _________________ how to navigate health care (what questions to ask, what compliances to employ, how to utilize health care services, etc.)

payment

centers of medicare and medicaid services (CMS) innovation ______________ is based on the quality and value of care

demand

consumer's willingness to purchase goods or services

containment

cost ________________ efforts include... - High and increasing rates of generic drug use - Shift from inpatient to outpatient hospital care - Price control measures on healthcare plans

frequently

despite high spending, Americans do not go to the doctor very ________________ compared to other countries

stage 1

developmental stages of health care: (1800-1900) - infectious epidemics - inadequate and unsafe hospital care - minimal technology - experience-based training

stage 2

developmental stages of health care: (1900-1945) - acute infections are the main focus - trauma - specialty hospitals emerge - therapeutic advances - shift to science-based training

stage 3

developmental stages of health care: (1945-1984) - chronic diseases are the main focus - increasing numbers and types of facilities - durable technologies-- therapeutics and diagnostics - development of medical specialties, new 'types' of employees

stage 4

developmental stages of health care: (1984-present) - emergence of new and old infectious diseases - mergers, "integration" - "super" drug therapies computerization - service technologies - primary care, "turn" issues, multidisciplinary care teams - managed care

DRG

diagnosis related groups; provision of healthcare that provides fixed reimbursement to hospitals based on weighted formulas (billing)

yes

do nurse practitioners, clinical nurse specialists, and midwives receive reimbursement for their services?

SDOH (social determinants of health)

factors shaped by the distribution of money, power, and resources throughout local communities, nations, and the world - The complex, integrated, and overlapping social structures and economic systems that are responsible for most health inequities. - social environment, physical environment, health services, and structural and societal factors.

macroeconomics

form of economics that is aggregate supply and demand. includes production, consumption, investment, international trade, inflation, and unemployment - this is a large view of economic stability and growth - GLOBAL perspective of variables affecting the total economic picture (large scale health financing picture such as national health plans) (ex.) looking at quality/pricing of hospitals and the reimbursement of CMS rather than the nurse: patient ratio

microeconomics

form of economics that shows how supply and demand can be used in healthcare - shows a good idea of what the pricing will be depending on the demand the amount of goods available

Fee-for-service (FFS)

form of paying health care practitioners; the traditional method of paying health care practitioners (similar to retrospective reimbursement) - costs are determined for providing a service, delivers the service, submits a bill for the delivered service to a third-party payer

Medicare

government support that provides health insurance and medical insurance to persons 65 years of age and older, permanently disabled persons (2 years with the disability), and to persons with end-stage renal disease

Medicaid

governmental support that provides financial assistance to states and counties to pay for medical services for poor older adults, the blind, the disabled, and families with dependent children - jointly (shared) sponsored and financed with matching funds from the federal and state governments - people need to qualify for this

no

has spending on health care kept pace with inflation and less workforce contributors?

insurance

health _____________ companies set different prices for the same goods and services (hip replacement make cost less in Minnesota compared to New York) - health care does NOT truly represent a competitive free market

TRICARE

health care for the military - federally funded health program that provides beneficiaries with medical care, supplemental to that available in US military and Public Health Service facilities

hospital

health care spending: largest portion of health care expenses are from _______________ care and physician services - only a small fraction spent on home health, public health, research, and construction - readmissions alone cost $26 billion in a decade - Medicare proposes to pay less to hospitals with higher-than-average costs for patient care

rationing

health care spending; to solve rising health care costs, all plans for future payment include some form of...

unpredictable

healthcare is _______________ and difficult to research - does NOT truly represent a competitive free market

risk-sharing fund (high-risk pools)

high-risk ideas for coverage; a mechanism to subsidize insurance coverage for the seriously ill or for people with high medical costs. a sum of money ($50 million for seed grants to help states establish high-risk pools, $2.5 billion annually for 10 years to help states fund high-risk pools)

$2000

if an individual does not pay the mandate required in the ACA, they can penalize employers up to ____________ per employee

mandate

in the ACA, provisions includes an individual _______________ (tax or levy) of up to 2.5% of one's household income or 400% of federal poverty level eligible for Medicaid

higher

in the ACA, there was an increase in revenue streams, an expanded tax on ___________ income individuals and families

secular trends

marked changes in physical development that have occurred over generations. in health care economics, includes... •Historical payment systems •Unnecessary use of services •Lack of preventative care •Lifestyle/health behaviors •Societal belief that disease would be eliminated •Technological advances •Aging of society •Utilization of drugs becoming more and more of a problem •Shift from non-profit to for-profit health care

social security act

medicaid established act that provides universal health care coverage for the indigent and children - priority participation is given to children, pregnant women, and the disabled - childen under the age of 18 are eligible for CHIPS (Children's health insurance program) Mandated covered services: 1.inpatient and outpatient hospital care 2.lab and radiology services 3.physician services 4.skill nursing care at home/or in SNF 5.family planning

Cadillac

part C of medicare that is also called medicare advantage that was made into the program

part A

part of medicare: (hospital insurance) when you are not working, automatically qualified once you turn 65-- includes inpatient care in hospitals/skilled nursing facilities, hospice care, and some home health care - must pay a deductible for. health services - does not pay for all health care costs of enrollees'' "gaps" in Medicare coverage

part B

part of medicare: (non institutional care insurance) purchased by monthly fee that helps pay for physician services, hospital outpatient care, durable medical equipment, and home health, and other medical services (diagnostic and physiotherapy) - not compulsory - after you retire and no longer have an employer that takes care of insurance. - the more money you take in as a retired person, the more money you have for this

medigap

part of medicare: used to cover the extra 20% of health care costs that medicare/medicaid does not cover - CMS usually only covers 80% of health care costs, patient is responsible for the remaining 20%

retrospective

paying health care organizations; ___________________ reimbursement is the traditional reimbursement method, whereby fees for the delivery of health care services in an organization are set AFTER services are delivered/rendered - paying for the services after it was completed - difficult to contain costs

prospective

paying health care organizations; ___________________ reimbursement where the third-party payer establishes the amount of money that will be paid for the delivery of a particular service before offering the services to the client - payment based on rates derived from predictions of annual series costs set in advance of delivery of service - more recent method of paying organizations

efficiency

principles of economics: depends on task and process-- the method in which a task is completed to reach a goal

effectiveness

principles of economics: extent to which a stated goal is met - "did I actually make it to the task I intended to?"

premiums

private insurance coverage changes as a result of the ACA; insurance ______________ (Items offered free or at a minimal cost as a bonus for purchasing a product) can now only vary by age, geographic location in some areas, and SMOKING STATUS

lifetime

private insurance coverage changes as a result of the ACA; insurers are not allowed to set _____________ policy limits

80%

private insurance coverage changes as a result of the ACA; insurers must return _______ of premiums to policyholders or provide additional health benefits - no significant change in medical loss ration (overhead/spending)

HDHP (high deductible health plan)

provision of healthcare that has employers pay lower premiums. a health plan that combines a Health Savings Account (HSA), traditional medical coverage, and a tax-advantaged way to help save for future medical expenses while providing flexibility and discretion over how you use your health insurance

supply

quantity of goods and services

allocation

resource _______________ in health care: the distribution of health care is affected largely by the way in which health care is financed in the US - "follow the money"

reimbursement

select public health programs receive ___________________ for services through... - grants given by the federal government to states for prenatal and child health - medicare and medicaid for home health, nursing homes, WIC programs, and EPSDT through collecting of fees on a sliding scale for select client services

competitive

success of supply and demand depends upon a _____________ market - universal health care is the opposite of a competitive market - ACA - CMS innovation (improve quality and efficiency)

majority

the _____________ of the US population do have health insurance

federal

the ______________ government pays a major portion of the nation's health care - evolved through the 20th century from a system financed primarily by the consumer to a system financed primarily by third party payers - in the 21st century the consumer is being asked to pay more

uninsured

the ______________ individuals in American include those with low-paying jobs, part-time jobs, and/or temporary jobs - adults between ages 19 and 64 years - most are men - most live in the South - most of high school education or less

Prevention and Public Health Fund

the affordable care act addressed discretionary allocation and use of public health money by creating... - $15 billion were allocated here - the nation's first mandatory funding stream dedicated to public health programs - President signed legislation that cuts the fund by $5 billion over 10 years to help pay for other initiatives - continued cuts/continued reduction in funds

$947

the average American's prescription cost is... - WAY more than any other country

equity

the culture of poverty, The Wellesley Institute; research shows the critical necessity for ensuring that there is a health _____________ lens in the poverty reduction plans - this study showed that for every $1,000 increase in income, leads to substantial increases in health - an increase in income does not guarantee good health - decreased income almost inevitably ensures poor health/significant health equity

50.7%

the federal government is responsible for paying _______ of the health care coverage

least

the health care system has the ___________ effect on health care outcomes - BEHAVIOR and LIFESTYLE have the greatest effect on health care outcomes

health economics

the science concerned with the scarcity of resources and how this affects the health care industry

economics

the science concerned with the use of producing, distributing, and consuming resources, services, and goods

60%

the sickest 5% of patients cause more than ________ of health care costs

conflict

there is _____________ between regulation by government and reliance on market competition to distribute health care services - cost containment and value

private

there is an increased use of the emergency department by people who have __________ insurance

spending

trends in health care ______________ (increase) •Aging population and the greater prevalence of chronic disease •Advances in medical technology: consumers request cutting edge (accounts for 40-50% of health care costs increase) •Rising prescription costs (R & D) •High costs of insurance administration (addressed with ACA) •Cost sharing / grants •Health alliances (ACO) •Self-insurance / concierge •Flexible spending accounts (HSA and MSA) •Health promotion and disease prevention

medicare

trends in health care spending (increase); ______________ enrollees who have lived most of their lives with insurance now have higher health care costs and longevity

defensive

trends in health care spending; ______________ medicine includes excessive tests and x-rays ordered

increase

when competition is absent (in such cases as the implementation of the ACA), health care prices can _____________

HSA (health savings account)

when you contribute pre-tax dollars to the account for expected medical expenses for the coming year-often set up through your employer-submit claims and receipts for reimbursement up to amount deposited. - these will NOT be emptied at the end of the year (will roll over)

decisions

whoever is paying the bills for health care financing are the ones making the health care ______________ - excessive and inefficient use of goods and services in health care delivery has contributed to rising costs of health care: efficient use of resources