440 Final Exam

Health Maintenance Organizations (HMOs)

-usually the least expensive -you choose your MD from a list -see them for routine visits -if need additional treatment these physicians act as "gatekeepers" -a co-payment Positive Aspects -cost is low -copay covers all office treatments -a set fee for specialists, ER visits, and hospital expenses Negative Aspects -have to choose from doctors on list -may not be able to see a preferred physician or pay extra if you do -"gatekeeper" decides if you need a referral -certain procedures not covered -"assembly line" to make up for lost $

State Children's Health Insurance Program (SCHIP)

-a state by state run program -for children whose parents do not qualify for Medicaid but have a low enough income that they cannot afford private insurance

criteria when choosing a doctor

1. check education and accreditation 2. assess communication style 3. able to answer questions regarding tests, test outcomes, and test results 4. culture, gender, and launage as a factor 5. hospital priveleges 6. use itnernet resources (e.g. WebMD) to locate reviews/ratings

criteria when choosing a medical self-help program

1. info must by authorized 2. should support the doctor-patient relationship not replace it 3. confidentiality is stated to be secure 4. info backed by referenced research and dates 5. includes working links to additional resources 6. provides a valid emial address for a webmaster 7. provides disclosure of funding sources 8. a clear division between editorial content and any advertising

Positive & Negative aspects of Health Care Reform in MA since 2006

Positive

Preferred Provider Organizations (PPOs)

Positive Aspects -allows you to select your own MD -if favorite MD not on list there is a cost but often still cheaper than HMO Negative Aspects -but the basic cost (premium) is higher -some plans require a referral for specialists and some don't

In 2013, what will be the expectations for taxpayers?

medicare payrolls taxes increase & expand to include unearned income for individuals making > $200,000 & families making > $250,000

Medicare

over age 65 and have contributed to social security -available to all who qualify for social security benefits Part A -pays a % of hospital visits, in-home health care, and inpatient skilled nursing care and hospice Part B -covers outpatient care, doctor's services, physical or occupational therapists & additional home health care -most pay a premium for this option Part C -a combo of parts A & B Part D -is for prescription drug coverage -has a variety of drug coverage options -has a premium to be paid

Deductibles

a fixed amount yo pay before your health insurance coverage begins

Copay

a fixed amount you pay when you get some services

Medicaid

for low-income families -state and federally administered -for state determined low income -pays medical provider not the patient -usually covers doctors, hospitals, diagnostic services, dental, long-term care and possibly others as determined by each state

In 2018, what will be the expectations for taxpayers?

high cost employers - provided policies ($27,000 - family of 4, $10,200 individual) are subject to 40% excise tax

Premiums

the amount of money you pay for health insurance. determined by zip code, BMI, tobacco use, age and gender

In 2020, what will be the expectations for medicare prescription-drug beneficiaries?

the prescription-drug coverage gap is eliminated

In 2014, what will be expectations for: the uninsured, insurers, employers?

uninsured - most required to purchase insurance or pay a penalty insurers - prohibited from refusing to sell policies and limited in setting prices upon health status employers - N > 50 workers must provide coverage or pay a penalty

Difference between single-payer health care, single-payer universal health care, and single-payer health insurance

single-payer health care -funded from a single pool -run by the state -one buyer faces many providers single payer universal health care -funded from single pool -run by those who contribute to the pool -one buyer faces many providers single payer health insurance -one group collects all medical fees & pays all bills through a single source (UK's national health service, Canada's medicare) -administration hrs are 15 hrs/wk/dr vs. 53 hrs/wk/dr in us -if US decreased to canada levels = $28 bill savings.yr --> wait long time for care

Steps the state of Utah has taken for state-wide health care plan

1. requires the executive and legislative branches to work on reform 2. develop standards, and standardization, for application and submissions -standardize applications -standardize insurance cards -increase ways to improve efficiency along with accuracy 3. raise the threshold at which a person can be denied coverage 4. expand the options for less costly employee-based programs 5. seek federal support for an individual to purchase private insurance 6. shifting more responsibility to the consumer -can have a group of one -create more lower cost options (lower than current consolidated omnibus budged reconciliation act of 1985 - COBRA plans) 7. require all state contracts involving design and construction projects to provide health insurance coverage 8. initial results from fall 2009 -more employers are offering benefits -fewer are uninsured -true portability - workers can transfer their current coverage to a new job -more choice, more competition; more transparency -more coverage for less cost 9. Initial recommendations from Fall 2009 -make selection process easier to understand -pricing disparities between contribution and coverage -better equalization of rating procedures

The 2010 Health Care Reform Bill

1. the uninsured - immediate access thru high risk pools if excluded before for pre-existing conditions; children remain on parents' plans until age 26 2. employers - small business (N<25) receive tax credits to purchase insurance; (N > 50) pay for or receive a fine - should keep worker costs down 3. Health insurers barred from: removing coverage when a person gets sick, denying coverage to children with pre-existing conditions, imposing lifetime coverage caps) 4. Medicare Prescription-Drug Beneficiaries (receive a $250 rebate when drug costs exceed $2700, eliminates "the doughnut hole" - costs between $2700 - $6154 where currently there is no coverage)

Explain what the Cleveland Clinic has done to implement a health care plan in a hospital setting

1. use patient info to create individual health plans which promote wellness, prospectively delay disease, customize disease management 2. provide the tools and resources to integrate personalized healthcare into clinical practice 3. empower patients to actively participate in their own healthcare 4. consolidate hospitals: reduce the number in an area and increase electronic sharing 5. bundle services rather than separate payments to a surgeon, anesthesiologist, MRI tech, hospital, lab, and others there is on payment to be shared by all 6. pay for keepign patients well rather than performing procedures when they get sick 7. transparency and competition: make health outcomes public and let patient choose

describe quackery and some its alerts

Any treatment which shows no effect, becomes harmful and/or delays acceptable and effective treatment 1. tends to target specific individuals 2. promises quick solutions to complicated problems 3. secret formulae from only one source 4. promise cures for a disease with no known cure 5. testimonials without medical references 6. money back guaranteers if not satisfied 7. require advanced payments, offer addditional procedures, or bonuses with purchase (or have limited supply) 8. free trials which ask for additional info 9. use terminology such as "scienfic breakthorugh" or "miracle cure" 10. incorrect claims -or must be supported by scientifi evidence (e.g. low fat decrease CV disease) -there is any confusion!

Coinsurance

a percentage amount that you pay when you get some services