HH Test #2

***Managed Care What is it? Why did the federal government want to expand it? What are its main elements? How is it different from traditional private pay insurance? What are the different types?

-1973 the Health Maintenance Organization Act -Provided federal assistance for the establishment and expansion of managed care programs. -Encouraged alternative to traditional health insurance which was less costly since it encouraged outpatient care. -Hoped HMO's would decrease the number of hospitalizations by increasing access to preventative care on an outpatient basis. -Required employers to include HMO as an option in an employee's health benefit package. -Primary care physician is the gate keeper -Most employers do offer HMO options -All managed care have the following elements: -Selected providers have been arranged to provide care. -Explicit standards for the selection of providers. -Formal programs for quality assurance and utilization review. -Financial incentives to members to use preferred providers and procedures covered by the plan -Usually prepaid or fee for service. -Beneficiaries pay a monthly fee with possible set copays. -Physicians and other providers have contracted amount of reimbursements which reduces negotiation power of the providers

***State unemployment/Old Age insurance What states were most successful? Which states had insurance?

-30 states had some form of old-age pension program by 1935. -Most were inadequate and ineffective. -Most were very restrictive. -Hard to get funds out of the state -Ohio and Wisconsin had the most successful programs. These programs served as the basis for Social Security.

How did hospitals change in the 1930's?

-After the Great Depression, hospitals were receiving less money. -Nurses did not always receive a salary, but worked for room and board. -Less money to spend on maintaining facilities or put into research. -Many hospitals fell into disrepair or closed.

Francis Townsend Who were they and what economic program are they linked to?

-An American physician. -Developed the Townsend Old Age Revolving Pension Plan in 1933. -Government gave $200 per month to citizen if older than 60 years. -Plan was to be funded by 2% national sales tax. -Eligibility: -Had to be retired. -Past had to be free from "habitual criminality." -All money received had to spent in the U.S. within 30 days of receiving it.

Spanish American War

-April 1898 to December 1898. -Clara Barton's involvement and development of the Army Nurse Corps based on her group of nurses. -X-rays first used on soldiers. -95% of wounded soldiers recovered. (healthcare really did advance)

World War I What medical advances were developed due to the war?

-Began in 1914 (American involvement in 1917) to 1919. -Prosthetics were improved and standardized. (3D printing is used nowadays) -Hard helmet were developed due to increase in head injuries (trenches). -Due to the war, the United States national health insurance due to the feelings for Germany. -Women were in the War—ambulance drivers and surgeons. -More infection due to battles on farm land (mud and manure (clostridium tetanide in manure)). -Motorized ambulances and hospital trains to transport soldiers. -Blood transfusions were being done--UK (needed to be stored—first blood bank). -Use of saline and blood to treat shock. -No antibiotics, but did use antiseptics. -"Shell-shock"—debate on physical or psychological cause —a reaction to the bombardment and fighting

The Blue Cross/Blue Shield Plan When was it established?

-Blue Cross provided hospital services and-Blue Shield provided physician services. -Blue Cross and Blue Shield became a joint corporation in 1982. -Today Blue Cross/Blue Shield includes people in the Federal Employee Health Benefits Program. -Blue Cross/Blue Shield has over 100 different plans. -Hence why it's a complicated system

***Pennsylvania Hospital Who founded? What was the hospital known for? How was it funded?

-Built especially for poor. -Raising funds was difficult -Contribution boxes -Ben Franklin wrote a history of the hospital which was sold for money. -Displayed religious painting—"Christ Healing the Sick in the Temple"—was displayed for a fee. -Tickets sold to walk through wards or watch surgeries.

What are some problems with managed care?

-Decreased quality of care. -Beneficiaries did not like the restricts on selection of providers, limits on services, and decreased quality of care. -Physicians and patients did not like the intrusion (interference) into their relationship. - Managed care is population rather than individual focused. -Beneficiaries wanted more government involvement in regulations.

Discovery of x-rays/inventor

-Discovered by Wilhelm Conrad Rontgen in Germany. -X-rays penetrate human flesh, but not bone or lead. -They can be photographed. -Won Nobel Prize for physics in 1901. -Believed to be harmless. (at first, x-rays weren't damaging)

***National Health Insurance Act in England How did it work? How was it paid for?

-England: 1911, National Health Insurance Act. -Provisions against sickness and death. -People received cash benefits to replace lost wages. -Provided medical care during sickness. -Paid by employees, employers and state. (tried to bring this model to the U.S.

***Quality Initiatives for Medicare What are they? How do they work?

-Established by Centers for Medicare & Medicaid Services (CMS) in 2001. -Focusing on quality -Collects and analyzes data to monitor conformance to established standards of care and performance. -Uses pay-for-performance plans by Medicare. -Designed to improve quality and avoid unnecessary costs. (still practiced today) -Website "Hospital Compare" was designed to show which facilities had the best performance of evidence based practice. -As of 2008 Medicare does not pay for hospital acquired infections and other "never happen" events.

***Medicare Which president signed into law? What is an entitlement program? Who is covered? How is it paid for? What are the differences among the different parts?

-Established in 1965 (President Lyndon Johnson). -(what group gets that money) -Citizens who are 65 years old or older, Individuals on SSDI. (Social Security Disability Insurance)(blindness is the #1 disability), Citizens with end stage kidney disease, and Citizens with Lou Gehrig's disease. -through social security tax - all the part shave different purposes ******Medicare prohibits federal interference with practice of medicine and the way medical services are provided.

***Emergency Medical Treatment and Labor Act When was it established? What does help to prevent?

-Established in 1986. -Many hospitals denies services to people who were unable to pay for services. -Many hospitals would not "accept" Medicare patients due to DRG's and could not make any profit. -They wanted people with insurance over those with Medicare -Act established that all hospitals must treat patients presented at the emergency department regardless of ability to pay. - triage care: determine how serious an injury is -Hospitals are not allowed to transfer patients after stabilization unless the other facility offer -Hospitals don't like this

***State Children's Health Insurance Program Who is covered?

-Established through the Balanced Budget Act of 1997. -Federal money is given to states to cover uninsured children. -To qualify, the family income must be too high for Medicaid, but too low for private health insurance. -Funded by federal and state money.

***Social Insurance Where did it begin? Who was an early supporter? What does social insurance mean?

-First began in Germany in 1889. -By 1935, 34 nations already had social insurance. -Government sponsored efforts to provide economic security for citizens. -Social=broader objective than the individual. -Insurance=protection against a defined risk. -Theodore Roosevelt was one of the earliest supporters.

Thomas Paine/ who was he/what significance

-Founding father -Came in 1774 -Wrote "Common Sense" talked about the colonists independence from Great Britain -Friend—Benjamin Franklin -Arranged money from France for the American Revolution -1795 -"Agrarian Justice." everyone should have property and a certain income -Controversial. -People inheriting property would pay 10% inheritance tax. -21 years old, 15 lbs of sterling to begin life. -50 years, annual benefit of 10 lbs sterling to guard against poverty due to old age. -Beginning of social justice system

***Part B of Medicare What is covered? How do people pay for part B?

-From 1975-1987, freeze on reimbursement to physicians. -Physicians increased number of patients to increase reimbursements.(only way physicians could increase their money amount) -1989 changed to resource based relative value scale (RBRVS) to replace fee-for-service which controlled cost by giving same amount for the same services. -Physicians used less expensive procedures. Caused incentive to decrease specialization of physicians. (patients were not being referred to these doctors)

Changes in medicine in the 1930's

-GREAT DEPRESSION -hospitals were receiving less money -nurses worked for room and board -there was less money to spend on fixing up hospitals -many hospitals closed

***Sickness insurance in Germany What is it? How does it work? Where did it start?

-Germany -Sickness insurance in 1883. -Gave cash payments for loss of wages. (from government) -Gave some provisions for physician fees. -By 1930 30% of Germany was insured. (not a lot)

Charles E. Coughlin Who were they and what economic program are they linked to?

-Had a weekly radio show. -Mix a little religion with a lot of politics. -Wanted a deliberate inflation of currency. -Wanted nationalization of all banks. -Was an anti-Semite and isolationist. -He was finally censored by the Catholic Church. -Was erratical -Eventually was censored

How did hospitals change after Medicare and Medicaid?

-Hospital admissions dramatically increased as did length of hospitalizations. -This increase in hospitalizations also fueled the increased cost of medical care. -Hospitals were losing focus of charity care and were more focused on making more capital. -Hospitals which did not make significant incomes closed.

Why are physicians and hospital relations strained?

-Hospitals and physicians charge are reimbursed separately. -Relationship is very stressed with quality initiatives and reimbursement requirements. -Use of hospitalists is increasing. -Employee of hospital -Do not provide follow-up care -Difficult for transfer of medical records

How did hospitals change in the 1920's?

-Hospitals had become basis for medical research. -New medical technology meant that people were hospitalized for these new treatments. -Hospitals no longer had a negative stigma. -More advanced surgeries in the hospitals. -Hospitals were used for life threatening illnesses, not just chronic illnesses. -More private insurance companies were becoming established after sick insurance and Blue Cross. -Hospitals receiving more money than ever before.

***Religious Hospitals Why were they established? Why did they flourish here? Which country had the biggest impact on American hospitals and why? Who ran and why did they want to do this? How were they funded? How have they changed today?

-In the 1800's Catholic nuns traveled across the country to establish schools and hospitals. -Their mission was to help the needy and spread Catholic religion. -Between 1850 and 1950, these religious facilities were unmatched by other founders of hospitals. -This happened during a time when women did not traditional have leadership roles in society. -Catholic church mission -Help the needy and spread religion -Nuns were doing this -Reasons Catholic hospitals flourished in America Rapid immigration and emigration. Rapid growth of urban and rural communities. No organized health and social services. Freedom of religion. Limited governmental restraints. Ireland -Had the biggest impact on American hospitals. -Wealthy Irish women joined or founded Catholic congregations. -Mother Catherine McAuley founded Sisters of Mercy. -Male clergy had difficult time dealing with these women leaders. -Recruited throughout Europe for novices to come to America. -Desirable to women who did not want to marry or become a teacher. -Offered opportunity to acquire new skills, travel, and do interesting things. -Assured of food, stable living environment and moral living -"Took in" people who had no where to heal. -Supported by charity of congregation (limited), sisters begging, borrowing money, and charging fees. -Limited regulations to start hospital. -Served entire community regardless of religion. -During Civil War, nuns served as nurses. -After the Civil War, hospitals were more respected. -Physicians used hospitals for diagnosis and laboratory testing. -Nuns promoted hospitals for providing valuable care. -Nuns also assisted in promoting nursing as a valued profession. -Less number of women becoming nuns. -Less nuns available for vocational positions in religious hospitals. -Today many religious hospitals have some nuns in administrative roles, but the number is declining. -Many religious hospitals use lay people in executive and management positions

The Blue Shield Plan What year was it established? What does it pay for? Who started it and why? How is it paid for, and how does it work?

-In the early 1900's, workers for the lumbering and mining companies paid a monthly amount for medical coverage for company physicians. -Official Blue Shield plan was started in 1939. -Started by the California Medical Association in an effort to protect the physicians' financial interests (wanted some input on what they were being reimbursed for) -Paid for by voluntary deductions from pay. -Used as a pre-paid plan (payment would be from funds available). (came out of check) -Paid on a unit system. Physicians determine how many units each treatment for a certain illness is worth. They received pay based on this determination. -More record keeping needed to maintain information for payment services. -Record keeping was narrative and hand written -Plan did not dictate how a physician could practice.

What caused the increase in health care costs after 1900?

-Increased medical and diagnostic technology. -Increase in specialty medicine. -Lower use of preventative medicine. -Later use of medicine leads to sicker patients. -Increase in pharmacologic agents (research and marketing). -Health care is labor intensive industry. -Increased older adult population. -Increase in people who do not have insurance or the means to afford health care.

What changes in mid-1880's caused changes in economic security?

-Industrial Revolution. -More people worked in factories than farms. -More money and more stable; there are pensions and insurance -Urbanization of America. -Families moved to cities for work. -In 1920 for the first time, more people lived in cities than on farms. -Disappearance of the extended family. -Families did not live with parents. -Support system -Marked increase in life expectancy. -Advances in medical technology and improved public health increase life expectancy. -Ex: x-rays, germ theory, sanitation improved, antibiotics introduced, immunizations

What are the quality initiatives for hospitals?

-Institutes of Medicines recommendations. -Improve patient satisfactions scores -Better patient outcomes. -Better staff communication. -Electronic Medical Record. -Patient focused care. -Nursing primary care -Quality markers. Mortality rates, hospital acquired infections, patient complaints, patient falls, adverse drug reactions, unplanned return to surgery, hospital incurred traumas -Joint Commission and other accreditation boards. -Consumer quality boards—Leapfrog Group.

Huey Long Who were they and what economic program are they linked to?

-Louisiana Governor from 1928 to 1932. -U. S. Senator 1930. -Assassinated in 1935. -Nicknamed the Kingfish. -Wanted to run for president in 1936. -"Share Our Wealth" program -Confiscate money from the wealthy and redistribute the money to the poor. (like Robin Hood) -People over 60 years old would receive pension.

How did Medicare change insurance development?

-Medicare is always the standard for advances in insurance. -Commercial insurers were compared to Medicare, and need for more coverage was established. -As health care advances were developed, more citizens were open to national health insurance. (still doesn't occur in the U.S.) -Private insurance companies tried to improve coverage to quell the citizens complaints.

How did hospitals change in the 1990's?

-Mergers and acquisitions increased to stabilize hospitals. -Gain economy of scale. -Brand associations. -Increase bargaining power with managed care organizations. -Expanded horizontally and vertically. Closed or changed non-profitable facilities.

***Diagnosis Related Groups Why were they developed? What problems were they to fix? When was they established? How did they work?

-Originally physicians decided when patients were discharged from hospitals. -Physicians made treatment decisions without insurance input. -Hospital and physician costs increased due to long hospital stays. -Hospitals and physicians paid by fee-for-service and was retrospective. -Hospitals and physicians had no incentives to decrease costs. -For purposeful payment -Took away freedom from physicians -Increased technology, increased people covered (more older citizens and more citizens receiving SSDI), more covered services. -Private insurance companies raised premiums in the 1970's to the 1980's to offset health care costs. -Government responded to citizen's complaints about health care costs -Government realized Medicare was paying for uncontrolled costs and unnecessary hospital days. -Increased hospital costs meant increased Medicare payments. -Longer hospital stays put patients at risk for infections, they lost their ability to perform self-care, and other complications arose due to long hospitalizations. still like this nowadays 1983—the new system of DRG's was established for Medicare through Tax Equity & Fiscal Responsibility Act

***Hill Burton Act When was it established? How did effect hospitals? What requirement did hospitals do to receive?

-Passed by Congress in 1946 and was sponsored by Harold Burton and Lister Hill. -The act gave federal grants and loans to hospitals to improve the hospital system in the United States. -Hospitals were required to give a certain amount of "free care" each year to receive the money. -State and local government matched funds by the federal government.

Herbert Hoover Who were they and what economic program are they linked to?

-President 1929 to 1933. (During the depression) -Believed in the "invisible hand" or "volunteerism." (give money to others) -Wanted to limit relieve efforts. -Government intervention would hurt individuality and self-reliance. -Advocated for voluntary relief efforts which never materialized. -the country was economically unstable

What are the differences between ambulatory care and hospitals?

-Procedures done which do not require overnight hospitalizations. -Increased dramatically over the past 10 years. -Better insurance reimbursement. -Less expensive and most effective. -More accessible to public. -Attractive to physicians. -More profitable.

***Social Security (remember reading from the Social Security pdf, pgs. 1-8 and 20-21, good article) When was it signed into law? Know Title V, XVIII, XIX How is it paid for? When do people receive benefits before the1939 amendment and after this amendment? Who received benefits with 1954 amendment? Who received benefits with 1956 amendment?

-Signed into law on August 14, 1935. -Part of Second New Deal (more liberal and controversial). Title V : Grants to States for Maternal and Child Welfare. Title XVIII: 1965, established regulations for the Medicare program, which guarantees access to health insurance for all Americans, aged 65 and older, younger people with specific disabilities, and individuals with end stage renal disease. XIX: regulations for the Medicaid program, which provides funding for medical and health-related services for persons with limited income. 1965 Originally benefits were only paid to the primary worker upon retirement at age 65. Benefit was based on payroll tax contributions that the worker made during his or her working life. Passed the social security act in 1935 Started collecting Social Security tax in 1937. Started paying Social Security benefits in 1942. Lump sum benefits were given between 1937 to 1940 for people who started paying the tax but were not vested. 1939 Amendment "Dependent benefits"—change to pay spouse and minor children benefits upon retirement. "Survivor benefits"—change to pay benefits to family upon premature death. Began paying benefits in 1940 instead of 1942. Amendment of 1954 Disability insurance program Provided disability "freeze" of worker's social security record during time of disability. Protected workers from losing benefits. Amendment of 1956 Provides benefits to disabled workers in a certain age group and disabled adult children -they could not work in the workforce Amendment of 1960 Expanded 1956 age limits to any age.

***Company Pensions How were they paid for? What conditions were required from the employees?

-Some paternalistic companies paid older workers to do token jobs for reduced pay. -Some companies withheld a percentage of workers pay to put into a pension. -Had to work for the company his entire life. -Lost pension if company went out of business. -In 1900, 5 large companies offered pensions (Baltimore and Ohio Railroad, Pennsylvania Railroad)

***Self -funded insurance How does it work? Who is covered? How is it funded?

-Started in late 1970's. -An employer group such as a union or trade group collects premiums and puts money into a fund. -Reimbursement for medical expenses came from the fund. -Does not use a commercial carrier. -An actuary firm sets premium rates and a third party does administration of benefits, pays claims, and collects data. -Employers avoid administration charges and premium taxes. -Controversy in the employers responsibilities to employees defined by the state. -States lose the premium taxes.

***Preferred Provider Organization How is it different from HMO's? How does it work?

-Started in the 1980's. -Coverage is fee-for-service and a choice of providers is offered. (more of a selection) -Out-of-pocket expenses for care is lower if preferred providers are used. -Higher deductibles, higher co-pays and other limits are incurred if members use providers other than preferred for care. -Some pre-certifications are required. -Some plans require second opinions on certain procedures. -Pay more for a PPO

The Blue Cross Plan Who established it? What year was it established? How is it different from sickness insurance? What does it pay for?

-The prototype for which Blue Cross was based was developed at Baylor University by Justin -Ford Kimball in 1929 due to the problems with the Great Depression. -Kimball was the vice president for Baylor University health care facilities. -Planned paid for hospital expenses of teachers, and the teachers paid $6 per year to be covered. -Initial plan was in 1929 which was provided by non-profit company. -Physicians did not support initially. (only reimbursed a certain amount/there was a cap) -Improved patients access to hospitals. By late 1930's hospital admission rates for Blue Cross participants were 50% higher than the remainder of the nation. -In the 1930's physicians began to see an increase in patients due to insurance, so then supported Blue Cross. -You were rewarded if you got other people to join insurance)

***Medicaid What year was it established? Who is covered? How was it paid for? How is money dispensed?

-Title XIX of Social Security -Established in 1965. -Mandatory federal-state program. Other state programs were dissolved. Program requirements are designed by each state although the federal government has established guidelines. -Coverage types: Low-income families with children Long-term care for elderly citizens and disabled citizens. -Supplemental coverage for low-income Medicare beneficiaries such as Medicare premiums, deductibles and coinsurance. ----Each state has different Medicaid programs Funded by payroll taxes matched by employers. Medicaid does not use intermediaries. Reimburses directly.

Claude Pepper/ his impact on health care

-U. S. Senator in 1943 -Established Wartime Health & Education -Issued report that concluded national health insurance was the only way all citizens would have access to health care. -This did not go through (wanted to take after England)

How do uninsured citizens affect hospitals?

-Usually use emergency room as primary care. -Emergency room functions as a safety net for the indigent. -Emergency rooms functions using triage. -Uninsured with minor issues clog emergency room. -Physicians must do "all necessary" testing for patients.

What are the different types of hospitals and what are their characteristics?

-Voluntary not-for-profit hospitals (Have a mission of charity, Must treat a certain number of uninsured patients, Receive tax credit from government, Must have a limit on money earned, Usually has a community board) -For-profit hospitals (Do not receive tax breaks from federal government, May be owned by a separate company or a group of physicians, Add units which attracts patients with insurance, Add units which will attract patients returning to hospitals) -Public or government hospitals (Usually provides community services other hospitals are reluctant to provide which are high cost and low return, Trauma centers, psychiatric, substance abuse, burn treatment, Veteran's Administration hospitals are the largest governmental hospitals (largest health care system).,Have the best records system,Have quality initiatives,Receive federal funding for operation.) -Teaching hospitals (Usually associated with a university or a medical school,Receives increased Medicare reimbursements, Have more advanced technology and more specialties,Usually cost more for hospitalizations,Usually conducts clinical research -Specialty hospitals (May be associated with another hospital, May be owned by physicians, May be not-for-profit or for-profit, Examples are orthopedic, women and children, psychiatric, surgery, Usually treats less complex, more profitable cases.

Voluntary hospitals effects on insurance development

-Wealthy donated for the poor. -Costs increased as technology and expenses increased. -Patients resisted paying increased fees. -Medical practice not specialized. -Limited preventative care. -Solution was development of insurance.

The Great Depression How did it affect health care?

-When the great depression start and what was the cause? Stock market crash and on October 29, 1929 -What changes occurred in health care? Cannot go to doctor b/c there was no money -After stock market crash on October 29, 1929. -Patients could not afford hospital charges. -Less patients in the hospitals. -Nursing staff in hospitals worked less hours. -Many nursing staff worked only for room and board. (even though there wasn't much for them to do) -Less private duty nursing was available. -Physicians' salaries dropped dramatically. -Limited preventative care.

F.D. Roosevelt Who were they and what economic program are they linked to?

-he was around in 1944 -Proposed economic "Second Bill of Rights" -Citizens have right to adequate medical care. - adequate had a hard time of being defined -Citizens have the right to achieve and enjoy good health -Promised national health insurance program. -Died before this was realized

***Act for the Relief of Sick and Disabled Seamen Which president enacted it? Who was covered?

-occurred in 1798 -President (John Adams) -Mandatory health insurance for any private employee working on Maritime vessels. -Compulsory deductions for hospital services were made from the salaries of sailors. -Protect sailor to cover if he became sick -(sailors never paid a premium) -Created marine hospital service

what is a deductible

A dollar amount that a patient must pay for health care services each year before the insurer will begin paying claims under a policy

what is a co-pay

A flat-dollar amount which a patient must pay when visiting a health care provider

what is the HMO (health maintenance organization)

A type of managed care organization (health plan) that provides health care coverage through a network of hospitals, doctors and other health care providers.

What is a PPO (Preferred Provider Organization)

A type of managed care organization (health plan) that provides health care coverage through a network of providers.

Balanced Budget Act of 1997

Added Part C to Medicare (Medicare + Choice). Added due to increased Medicare cost to federal government. Allowing private health plans to administer Medicare contracts. Shared costs through deductibles and co-payments. No limit to the out-of-pocket expenses. Provided incentives for hospitals to decrease number of medical residents.

***Certificate of Need Who administered? What does it prevent?

Administered by the state. With increased insurance and Medicare payments, more hospital and medical facilities were built. This legislation ensured adequate facilities were available to every citizen and avoided duplication facilities. Easier to get a certificate if you're in a system

***Part C of Medicare What does it cover? How is it paid for?

Changed Part C to Medicare Advantage. Added Medicare managed care programs. Increased enrollment

How insurance changed medicine

Early 19th century health insurance was started and designed to make up for lost income with a fixed cash payment. This sickness insurance was the beginning of social insurance programs. 1915 compulsory health insurance began in United States. It was to cover sickness In 1910, the American association of labor legislation drafted legislation for $50 for funeral costs, sick pay, maternity benefits Wasn't supported b/c unions were starting to rise Private insurance does not support this b/c they want to make money for themselves Not accepted, there were a lot of fights about it 1919 AMA condemned the compulsory health insurance. Physicians had a concern that insurance would decrease rather than increase physician incomes due to their experience with accident insurance which paid physicians according to an arbitrary fee schedule. A lot of people can make money off of this AMA condemned as unethical and expelled all GHI (great health insurance) salaried physicians. The AMA was fined for monopolizing medical practice. GHI physicians were ostracized and denied privileges in hospitals.

Reasons for increased cost of medical care

Increased cost of health care. Insurance premiums increased to compensate for escalating charges. Utilization review monitored and evaluated physician performance. (still in place today; is the physician doing what they're supposed to do?; should the person stay there an extra day?) Physicians were subjected to managed care policies and guidelines. )how to manage a certain type of patient) Meds are expensive

Benefits of group practice for physicians

Increased group practices supported physicians maintaining medical knowledge and knowledge of technology. Benefits of group practice Multidisciplinary practice Cover call hours and vacations (different specialists working together) Professional supportive environment Decreased reliance on patient referral Consultation services on one site Increased use of questionable, inappropriate and unnecessary services. Unaware of relative effectiveness of various procedures. We thought x-rays were safe 1989 Agency for Health Care Policy and Research developed practice guidelines. We see some awareness of problems and see ideals of practice

***What is social security disability insurance? Who receives benefits? Why don't physicians like it? Who is Wilbur Cohen and what did he believe regarding SSDI? What is the process to receive SSDI and how quickly can you receive it?

Only blind was first disability. Strong opposition from insurance industry and medial professions. Difficult to control by federal government at first since many people wanted to be considered "disabled" as opposed to "unemployed." Initially wanted to encourage rehabilitation instead of income maintenance. Wilbur Cohen (SS official) was supporter of more income maintenance since some disabilities could not be rehabilitated. Compromise to allow states to help with SSDI Workers must contribute long enough and recently to receive benefits unless disability started before age of 22. More refined state Strict definitions of disability set by federal government. 5 step evaluation process which usually takes more than 5 months to process. May appeal hearing if initially denied. It is hard to get disability insurance

***Children with Special Health Care Needs How is it connected to SS? Who provides the funds? Who is covered?

Originally called Cripple Children Services. One of the first medical programs under the original Social Security Act. Part of the Maternal and Child Welfare (Title V). Provide services to children with physical health problems. Fedral and State provides matching funds to finance programs. Initially limited to orthopedic issues but then slowly expanded to cover other health problems. 1963 Amendment expanded to include mental disabilities.

Part D of Medicare What does it cover?

Part D of Medicare was added which provided prescription drug coverage to low income individuals.

***Federal Emergency Relief Act What year was it passed? What type of coverage was available?

Passed in 1933. Federal aid to states. (states had the option of partaking in this) Authorized medical care for acute and chronic illnesses, obstetric services, emergency dental extractions, bedside nursing, drugs, and medical supplies. Participation by states was optional. Act not implemented in many parts of the country.

Physician shortage and specialization

Post World War II to mid 1970's developed a shortage of physicians due to insurance development, increase technology and increased patient volume. Federal government responded to shortage with money to double capacity of medical schools. increase (sponsor medical students in medical school) Federal government helped support attracting foreign trained physicians. Early 1900's no standard for specialty practice. Increased science knowledge and technology in 1940's to 1970's supported increased specialization of physicians. This specialization created a oversupply of specialists and decreased amount of primary care providers. Physicians were concentrated in urban medical centers due to increased reimbursement and increased technology. First specialty was opetamology (eye) Dermatology is the least needed (technically)

Causes of primary care physician shortage

Shortage of primary care physicians among rural and inner city populations. Medical schools increased capacity assuming that producing an oversupply of physicians would force more physicians into primary care in underserved areas. Certain specialists still exceeding supply. Medical schools have changed curricula to population-based (what can be done based of a certain population group) (ex: people w/ asthma) thinking, prevention, and cost effectiveness. Hospitals increased residencies to meet their own needs without concern for oversupply. Medicare payments increased for teaching hospitals. (usually higher)(for older people and lower income families) 1990's increased emphasis on primary care and prevention of disease. Primary care physicians became "gatekeepers"(come see me before any specialists) of inappropriate and unnecessary use of specialist due to increased managed care.

Sickness insurance Why was it established? How did it work? Why did people need it? How did it affect health care?

Sickness insurance in 1883. Gave cash payments for loss of wages. (from government) Gave some provisions for physician fees. By 1930 30% of Germany was insured. (not a lot)

***Part A of Medicare What is covered? How do people pay for part A? What is the intermediary company most hospitals use?

Supplementary medical insurance. -Voluntary. (extra payment comes with this) -Covers physician services and services ordered by physicians. -Intermediary is usually Blue Shield. (not true Medicare management controls this) -Beneficiary premium payments are deducted from beneficiary's Social Security which is matched by the federal government. (less in social security check)

what is a preexisting condition

The period of time that an individual receives no benefits under a health benefit plan for an illness or medical condition

***Civil War Pension Program What year was it established? Who received benefits? How was it paid for? What were benefits based upon?

Who helped establish the pension program for Civil War veterans? - established in north by the union -Confederates didn't have this - pension can be from where person is employed or from the government -1862 -Benefits linked to disabilities due to injuries sustained in the Civil War. -Level of pension was based on rank. - first pension was $8 a month -Widows and orphans received pension. -1906—any disable veteran may receive benefits (disability did not have to be due to war). -1910—90% of veterans received benefits. Causes economic shift -Attractive to young women, so they married older veterans (last surviving widow received benefits until 1999). -In 1894 military pension was 37% of federal budget. -Confederate soldiers did not receive benefits. -Policy makers did not link pension to need or degree of disability. -Policy makers paid little attention on how to finance.

what is a health reimbursement account

employer-funded plans: put into an account. Rolls over

what is a flexible spending account

how much money is put into an account for healthcare, does not roll over

what is managed care

one person telling you what doctor to see-from insurance or health care provider

What do hospitalists do?

physicians who focus on general medical care for hospital patients

what is a premium

what you pay each month for health insurance