Healthcare Basics Exam #1 Study

Patient has a health insurance policy with a $500 deductible and a $50 copayment for imaging. Patient has an MRI which costs $1000. Assume patient has already contributed $300 towards his annual deductible. What is the cost to the patient?

$250

define group model HMO

- 1 contract w HMO & 1 contract w physician group - physician offers services exclusively to HMO pts & are reimbursed on capitated basis

How are PPOs different from HMOs?

- HMO:capped models - PPO: providers are reimbursed on fee per service

examples of consumer driven health plans

- HSA: health savings account - FSA: flexible spending account - HRA: health reimbursement/retirement account

downside to COBRA?

- can be very expensive because individual pays full monthly premium

specialty care examples

- cardiologist - oncologist - dermatologist

Public federally ownership examples

- department of defense - indian health service - veterans health administration

primary care specialties

- family medicine - internal medicine - pediatrics

what are other government insurance programs besides medicare, medicaid, and S-CHIP/CHIP & who do they benefit

- indian health services: for native americans & alaskan natives - veterans health administration: veterans + their families at low to no cost - TRICARE: for active duty military members and some retirees + dependants

different between large and very large employers?

- large: opt in model, decide to enroll - very large: opt out, automatically enrolls, but can decline

benefits to employer sponsored insurance/group health plan

- lower premiums (bc its divided w employer) - benefits arent tied to income taxes bc they're provided by employer

Public state ownership examples

- mainly long term care facilities for mental illness - a few hospitals

what does COBRA do?

- not an insurance policy - law that allows person to retain employee sponsored insurance if fired, quit, or no longer qualify

name the 3 types of non hospital inpatient settings

- nursing homes - long term acute care hospitals (LTACHs) - inpatient rehab facilities

physician owned hospitals

- owned by physicians, usually of single specialty - usually for profit --> profit goes back to physician group - becoming less popular

for profit

- owned by private corporations - profit goes back to share holders - pays taxes

not for profit

- owned by secular or religious orgs - profit goes back into hospitals or community - dont pay taxes

define capitated basis

- per member, per month rate - fixed - not based on # of services used/not used

examples of outpatient facilities

- private practice - hospice & home care - community pharmacies - non physician services: dentists, chiropractors, physical therapists

define consumer-driven health plans

- tax free bank accounts used for medical expenses

Approximately what percent of gross domestic product (GDP) is currently spent on health care in theUnited States?

20%

Which statement correctly describes employer-sponsored insurance?

As health insurance costs rise, employers are shifting more costs to employees with greatest increases in the cost sharing burden to employees

Which statement correctly uses insurance terminology?

Beneficiaries on a health insurance policy are either subscribers or dependents.

This agency within the US Department of Health and Human Services administers the Medicareprogram

CMS

Profit is distributed to shareholders in which hospital ownership structure?

For profit hospitals

In which model does the payer (i.e., insurance company) have the greatest control over physicianactions (e.g., prescribing medications, requesting imaging, or placing specialist referrals)?

Group Model HMO

define staff model HMO

HMO ownership of healthcare facilities AND physicians

This legislation required employers with more than 25 employees and offering health insurance to include a specific plan type.

Health Maintenance Organization Act

Public health insurance programs include I: TRICARE II: CHIP III: COBRA

I & II

The payer/organization has significant control over physician actions in a.. I: staff model HMO II: group model HMO III: network model HMO

I & II

patient lens: - most flexibility?

IPA HMO

payer/insurer lens: which model is the least expensive & has least control over physician actions

IPA HMO

provider/physician lens: - which model has the most financial risk and physician autonomy

IPA HMO

what HMO has a further level of disconnect between insurers and individuals?

IPA HMO

what HMO providers aren't paid on salary + theres a risk of not being able to pay bills

IPA HMO

What type of insurance model is characterized by physicians forming a separate legal organization thatthen contracts with an HMO to provide services?

Independent Practice Association (IPA) HMO

Which statement(s) is true regarding fully-insured employer sponsored health insurance?

Insurance company assumes the risk

example of group model HMO

Kaiser Permanente - Kaiser health plan (insurer) + Permanente medical group (physician group)

A patient has been hospitalized for severe burns following a house fire. His condition has stabilized.However, he will require several weeks of sophisticated wound care, including daily dressing changes withsedation. What type of facility is he most likely to receive this care upon discharge?

Long term acute care hospital

Which of following statements is NOT true regarding the evolution of health insurance in the UnitedStates?

Major health care reform efforts were omitted/blocked as part of Franklin D Roosevelt's "NewDeal," Harry Truman's "Fair Deal," and Lyndon B Johnson's "The Great Society."

Which of the following is true regarding a preferred provider organization?

Patients are free to see any provider, but have financial incentives to see "in network" providers

Which of the following is true regarding a Network Model HMO?

Physician practice sites are owned by the physicians themselves or a health system

Which of the following is not a type of cost sharing?

Premium

Select the correct pairing

Primary care: family medicine

This agency is focused on reducing the impact of substance abuse and mental illness on America'scommunities.

SAMHA

Fully ensured employer health insurance - regulated by federal or state gov?

State gov

most hospitals are private T or F

True

main point to know about consumer driven health plans

a way for people to save up $$$, put it somewhere, and save it to pay for health expenses late

Food and Drug Administration

assuring safety, efficacy, and security of drugs, biological products, medical devices, food supply, cosmetics, and products that emit radiation

what is a patients experience with PPO?

can see any provider that contracts w PPO but theres financial incentive to see in network providers

simplified components of triple aim

care, health, and cost

what 3 costs go towards out of pocket max

deductibles + copayments + coinsurances

fully insured employer health insurance

employer buys insurance from private company

self insured employer health insurance

employer contracts w private insurance company

Self insured employer health insurance - who assumes financial risk?

employer is the payer and assumes financial risk

Self insured employer health insurance - who profits?

employer profits, they're paying the claim

most common type of insurance

employer sponsored/ group health plan

private healthcare insurance example

employer-sponsored insurance/group health plan

Self insured employer health insurance - regulated by federal or state gov?

federal gov

forms of public ownership

federal, state, local, prisons

Administration for Children and Families (ACF)

funds state, territory, local, and tribal organizations to provide family assistance, child support, child care, Head Start, child welfare, etc

Public local ownership example

general hospitals, usually for very low income pts

public healthcare insurance example

government: Medicare & Medicaid

What type of insurance model is characterized by a contract with a physician group who offersservices exclusively to patients on a capitated basis?

group model HMO

non hospital inpatient which setting are pts not usually medically complex but need comprehensive rehab

inpatient rehab facilities

Fully insured employer health insurance - who profits?

insurance company

Fully insured employer health insurance - who assumes financial risk?

insurance company is the payer and assumes risk

Substance Abuse and Mental Health Services Administration

lead public health and service delivery efforts that promote mental health, prevent substance misuse, and provide treatments and supports to foster recovery while ensuring equitable access and better outcomes

non hospital inpatient which setting do pts need intensive, hospital level care for weeks or months

long term acute care hospitals

National Institute of Health

makes important discoveries that improve health and save lives

what HMO contracts with multiple physician groups?

network model HMO

what model has physicians that are typically reimbursed on capitated basis but will see pts from variety of payers?

network model HMO

are private hospitals operated by the government?

not directly, but all hospitals that accept medicare and medicaid in some sense are funded by the gov

3 types of private hospital ownerships

not for profit for profit physician owned

non hospital inpatient which setting do pts need 24 hour case & assistance with daily living

nursing homes

what costs don't go towards out of pocket max?

premium

who coordinates specialty care

primary care

Agency for Healthcare Research and Quality (AHRQ)

produce evidence to make healthcare safer, higher quality, more accessible, equitable, and affordable

Centers for Disease Control and Prevention (CDC)

protects America from health, safety, and security threats, both foreign and in the US

Agency for Toxic Substances and Disease Registry (ATSDR)

protects communities from harmful health effects related to exposure to natural and man-made hazardous substances

Health Resources and Services Administration

provides equitable health care to the nations highest need communities (low income, people w HIV, pregnant people, children, parents, rural communities, transplant patients, health workforce

Centers for Medicare and Medicaid Services (CMS)

provides health coverage to 100 million+ people through medicare, medicaid, childrens health insurance program (CHIP) and health insurance marketplace

Indian Health Services

raise physical, mental, social, and spiritual health of american indians and alaska native to the highest level

payer/insurer lens: which model is the most expensive & has most control over physician actions

staff model HMO

patient lens: - least flexibility?

staff model HMO - confined to network created by that organization

provider/physician lens: - which model has the least financial risk and physician autonomy?

staff model HMO - has a reliable salary & organization is responsible for business side of things, makes sure profit exceeds expenses

Administration for Community Living (ACL)

supports the needs of the aging and disability populations, and improves access health care and long term services

what is a provider's experience with PPOs?

they accept discounted fees for services in exchange for patient volume and quick claims payment

define HMO

type of insurance company/entity that owns healthcare facilities or directly employs physicians