HSML 6202 Exam 1

What is a "short-term Stop-Gap Coverage" plan?

- Insurance option for people who leave an employer or have retired but are not yet eligible for Medicare, leading to a temporary loss in coverage. - COBRA 1985 allows for a limited time for employees to keep their employer's group coverage for up to 18 months but they are required to pay 102% of the group rate and the employer subsidy is no longer available. Still probably cheaper than individual insurance

What are the "Healthy People Initiatives?"

- Started in the 1980s - Renewable 10 year plans outlining key national health objectives to be accomplished during each 10-year interval - Under the leadership of the Surgeon General - Focused on increasing the span of healthy life; reducing health disparities; promoting individual responsibility and accountability for one's own health - Out of this came the requirement for the Community Health Needs Assessment (CHNA) and subsequently the requirement to create a Community Health Improvement Plan (CHIP) - Healthy People 2020 which includes new topics like adolescent health, genomics, global health, health communications, technology, and social determinants of health

Impact of Managed Care

- The larger rise of managed care had an impact upon hospital closures during the 1990s and transformed the delivery of health services in the U.S.. - Emphasized cost-containment and efficient delivery. - Stressed the use of alternative delivery settings when appropriate. - Lowered hospital utilization and thus profitability. - Between 1990 and 2000 it contributed to the closure of more than 200 rural hospitals, closed beds, and wings of hospitals to be converted into other uses

Karpman, Zuckerman, and Peterson's study found that the loss of Employer Sponsored Health Insurance would have been far worse except for what?

1. Adults in families losing jobs constituted only 17 percent of all adults. 2. Majority of those adults have thus far been able to maintain Employer Sponsored Insurance. 3. Others have kept prior coverage or found new coverage through the non-group market of Medicaid/CHIP.

Determinants of Health

1. Environment- physical, socioeconomic, sociopolitical, and sociocultural dimensions 2. Lifestyle- also known as "behavioral" risk factors 3. Heredity- genetic factors that predispose us to disease 4.. Medical Care- the "formal" care a person receives, focused on diagnosis and treatment rather than prevention

What does a program of health promotion and disease prevention consist of?

1. Health risk appraisal looking at risk factors 2. Interventions such as behavior modification to adopt healthier lifestyles or therapeutic interventions 3. Adequate public health and social services to minimize risk factors to prevent disease and contain spread of infectious agents.

What are some of the reasons for the rise in chronic diseases in the U.S?

1. New diagnostic methods, medical procedures, and pharmaceuticals have significantly improved the treatment of acute illnesses, survival rates, and longevity. The prevalence of chronic disease is expected to continue to rise with an aging population and longer life expectancy. 2. Screening and diagnosis have expanded in scope, frequency, and accuracy 3. Lifestyle choices, such as consumption of high-salt and high-fat diets and sedentary lifestyles

What are the ten (10) basic characteristics that differentiate the U.S. health care delivery system from most other countries?

1. No central agency governs the system 2. Access to healthcare services is selectively based on insurance coverage 3. Healthcare is delivered under imperfect market conditions 4. Insurers from a third party act as intermediaries between the financing and delivery functions 5. The existence of multiple payers makes the system cumbersome 6. The balance of power among various players prevents any single entity from dominating the system 7. Legal risks influence the practice behavior of physicians 8. Development of new technology creates an automatic demand for its use 9. New service settings have evolved along a continuum 10. Quality is no longer accepted as an achievable goal

Did the Affordable Care Act (ACA) do anything about prevention? If so, what?

1. No cost coverage for preventative services 2. "Prevention and Public Health Fund" for national preventative efforts 3. CDC established a national diabetes prevention program to reach people with prediabetes. Organizations nationwide offer diabetes prevention lifestyle programs and work to increase awareness of lifestyle changes

Be able to explain why tracing risk factors in people is important.

1. Risk factors help us determine what increases the likelihood of developing a particular disease. 2. To become ill there must be (a) a host; (b) an agent; and (c) environment external to the host (physical, social, cultural, economic). 3. Mitigate or eliminate the risk factors of one or more of the three risk factor area. Prevention efforts should focus on a broad approach because these 3 entities interact to produce disease.

What are the four (4) fundamental principles that underlie the concept of insurance (and risk)?

1. Risk is unpredictable for the individual insured 2. Risk can be predicted with a reasonable degree of accuracy for a large group or a population 3. Insurance provides a mechanism for transferring or shifting risk from the individual to the group through the pooling of resources 4. All members of the group share actual losses on some equitable basis

There were two historic events that led to the "accidental" development of employer-sponsored health insurance in the U.S. What were they?

1. The decision by FDR after his election in 1932 to NOT pursue universal health care coverage left a big gap in the need to insure against the growing costs of illness. 2. Private insurance emerged to fill this gap, first by non-profit Blue Cross/Blue Shield, and then by other private insurers. "The Blues" were then ready to sell insurance to employers when the chance came to do so during WWII.

The U.S. healthcare system is referred to as a "quad-function model." What does this mean?

A healthcare delivery system that incorporates four functional components- financing, insurance, delivery, and payment. These functions tend to overlap

Group insurance

A large number of people in a group will purchase insurance through its sponsor (obtained through an employer, union, or professional organization). Risk is spread out among the many insured, group insurance provides the advantage of lower costs than if the same coverage was purchased in the individual insurance market.

Subacute condition

A less severe phase of an acute illness. It can be a postacute condition, requiring continuity of treatment after discharge from a hospital. Ex. Ventilator, head trauma care

What was insurance originally intended to do?

A mechanism for protection against risk (risk: the possibility of substantial financial loss from an event of which the probability of occurrence is relatively small). People get insurance to protect their assets against catastrophic loss. It was not originally meant to pay for every penny of a person's healthcare costs.

What is a "phantom provider" that is the source of a lot of healthcare costs?

A phantom provider function in an adjunct capacity with the main provider (anesthesiologists, nurse anesthetics, and pathologists) and bill for their services separately. Item billing for these additional services makes it hard to determine the total price before the service is received.

Coinsurance

A set proportion of the medical costs that the insured must pay out of pocket. Ex. For a certain health care service covered by a health plan, a 80/20 coinsured may be required. Once the deductible has been met, the plan pays 80% of the costs, and the ptnt pays the remaining 20%

primary prevention

Activities undertaken to reduce the probability that a disease will develop in the future. Ex. Exercise programs to prevent heart disease, safety training at the workplace to reduce work-related injuries, prenatal care to lower infant mortality, immunization of children

What is medigap?

Also called medicare supplemental - Private health insurance that can be purchased only by those enrolled in the original Medicare program (a program that has high OOP costs) - Medigap plans cover all or a portion of Medicare deductibles and copayments/coinsurance that are not covered

What's a "third party administrator?"

An administrative organization, other than the employee benefit plan or health care provider, that collects premiums, pays claims, and/or provides administrative services for Medicare recipients. Insurance companies are an example of this.

What's the difference between the "insured" and the "beneficiary?"

Anyone covered by health insurance is called the insured or a beneficiary.

Why is pediatric ALOS longer?

Babies in the NICU may stay for weeks

Experience Rating

Based on a groups medical claims experience. Premiums vary from group to group because they have different risks. Ex. older people are higher risk and are expected to incur high utilizations of medical care, thus they are charged higher premiums. Cons: makes premiums unaffordable for high risk groups

Does "high technology" improve outcomes or cause an increase in healthcare costs, or both?

Both; the latest and best technology has good outcomes but creates competition for the latest technology to be purchased by hospitals. Costs must be recouped through utilization. Not everybody has access to these services.

Government program for children

CHIP (children's health insurance plan). Federal and state

Country that has NHI?

Canada

In the United States, what is the leading cause of death and disability... acute, sub-acute or chronic conditions?

Chronic diseases. - Almost 50% of Americans have at least one chronic illness - Risk factors are (a) family history; (b) age; (c) exposure to cancer causing agents; (d) diet; (e) obesity; (f) tobacco use; (g) dangerous behavior - 8.7 out of every 10 deaths are attributable to chronic disease

Tertiary Care

Complex provided for uncommon conditions; typically institution-based, specialized, technology driven

medical model

Defines health as the absence of illness or disease. This definition implies that optimal health exists when a person is free of symptoms and does not require medical treatment. This view emphasizes clinical diagnoses and medical interventions to treat disease or symptoms of disease, but fails to account for prevention of disease and health promotion

secondary prevention

Early detection and treatment of disease Examples: health screenings and periodic health examinations

Strategies for expanding the surge capacity of a hospital?

Early discharge of stable patients Cancellation of elective procedures and admissions Conversion of private rooms to double room Reopening of closed areas Revision of staff work hours to 12 hour disaster shift Callback of off duty personnel Establishment of temporary external shelters for patient holding

holistic medicine

Emphasizes the well-being of every aspect that makes a person whole and complete. Seeks to treat the individual as a whole person. Diagnosis and treatment would take into account the mental, emotional, spiritual, nutritional, environmental, and other factors surrounding the origin of disease. Spiritual dimension is also incorporated.

What is premium cost sharing?

Employers' requirement that their employees pay a portion of the health insurance cost.

Social Justice

Equitable distribution of health care is a responsibility of an orderly society; it is best achieved by letting the government take over the production and distribution of healthcare; considers healthcare as a social good and not an economic good; that it should be collectively financed and available to all citizens regardless of ability to pay. (Even with social justice, the government uses supply-side rationing also called planned rationing under the guise of "health planning" to limit supply. Note that even in spite of having public insurance, many Medicaid patients have difficulty obtaining timely access due to artificially low reimbursement.)

Practice of Medicine

Focuses on individuals, biological causes of disease, and the development of therapies and treatments. Wants to relieve suffering or restore normal function

Public Health

Focuses on populations, identifying risk factors or potential risks that may threaten people's health and safety and implementing population wide interventions to minimize these risk factors.

Country that has SHI?

Germany

Socialized Health Insurance (SHI)

Government mandated contributions from employers and employees finance health care. Private providers deliver health care services. Private, not for profit insurance companies, called sickness funds, are responsible for collecting the contributions and paying physicians and hospitals.

Main types of private insurance

Group insurance, self insurance, and reinsurance

Reading: Kenneth J. Arrow's seminal 1963 work entitled "Uncertainty and the Welfare Economics of Medical Care

Healthcare is an imperfect market, normal market forces don't apply. You cannot purchase healthcare the same way you buy toothpaste or other goods.

What is a "high deductible" health plan?

High deductibles & OOP, lower premiums They generally provide a savings option with a health insurance plan that carries a "high deductible" and have shown comparatively significant growth in recent years.

Big problem with employer sponsored health insurance?

If you lose your job, you may lose coverage

What is the primary difference in healthcare financing between the U.S. healthcare system and other countries with universal healthcare coverage systems?

In single payer systems of other countries, taxes are raised by the government to provide health insurance to the citizens, and private financing plays a minor role for those who want more extensive coverage. In the US, public and private financing both play large roles and insurance overlap is common.

What has happened to the major or top causes of death between 1900 and now?

Infectious diseases like pneumonia, tuberculosis, and diarrhea, were the top three killers in the U.S. It has changed remarkably from infectious diseases in 1900 to heart, cancer, chronic lung, trauma, cerebrovascular, diabetes, kidney disease and suicide.

tertiary prevention

Interventions that could prevent complications from chronic conditions and prevent further illness, injury, or disability. Examples: regular turning of bed-bound patients prevents pressure sores, rehabilitation therapies can prevent permanent disability, and infection control practices in hospitals and nursing homes are designed to prevent iatrogenic illnesses

What is managed care?

It is a system of health care delivery that tries to make HC more efficient. It aims to integrate the four functions of quad-function model. -It employs mechanisms to manage utilization of medical services - It determines the price of services (which determines how much providers are paid). - Integration occurs because of ensuring access to needed health services, emphasizing preventative care, and maintaining a broad provider network. Therefore allows for cost-efficiency.

What is a major feature of the U.S. Healthcare "System?"

It is incredible fragmented. People obtain healthcare through many different means.

In the course of your practice as a health services provider how much credence should you give to the client/patient's religious practice and spirituality?

It should be significant. Medical literature points to the healing effects of a person's religion and spirituality as an aspect of health care. Respect for patient values and beliefs are increasingly recognized as an important aspect of culturally appropriate care by the medical community. A number of medical schools now offer formal courses in spirituality in medicine.

When you heard people talking about the "pay or play" component of the Affordable Care Act... what were they talking about?

Mandate that required employers with 50+ full time equivalent workers to either provider their employees with health insurance or pay a penalty for not doing so.

Market Justice

Market justice leaves the fair distribution of healthcare up to the market forces in a free economy. Medical care and its benefits are left up to people's willingness and ability to pay for it. The free market implies that giving people something they have not earned would be morally and economically wrong. Healthcare is like any other economic good or service; individuals are responsible for their own achievements; people make rational choices in their decisions to purchase health care; people in consultation with their physicians know what is best for themselves; the marketplace works best with minimum government interference; and "rationing by ability to pay" is okay

What do we mean when we talk about a "continuum of services" in healthcare?

Medical care services (curative, restorative, and preventative) are no longer confined to a hospital or a physician's office. Additional settings have emerged for people at different levels of care (preventative to end-of-life). There is a heavier emphasis on specialized services.

Why does healthcare does not really behave like other marketable goods and services?

Medical services are typically more urgent, so consumers do not look for other options in the moment. People are not experts in the field. It is difficult for the consumer (patient) to be truly informed because of the extensive training that medical providers undergo.

What are the two largest government health care payers?

Medicare (federal) & Medicaid (federal & state)

Adjusted community rating

Middle ground between experience and community rating. Price differences take into account demographic factors such as age, gender, geography while ignoring other risk factors. ACA required use of adjusted community rating to determine premiums for individuals and small groups

Offshore Captives

Money in reserve or in investments through a captive company outside the country to use for insurance; just need to have one board meeting per year in that country or another country except the continental US; this is legal; a lot of large companies do this

What is "moral hazard" as it relates to health care spending and insurance?

Moral hazard is when consumer behavior leads to a higher utilization of health care services because of the services being covered by insurance. Health insurance means that there is more demand for covered services. More demand leads to higher utilization. This increase in utilization also positively affects healthcare services and technology in terms of advancements. If there was no insurance/less covered services, people would be less willing to pay the costs out of pocket so utilization would decrease. Insurance creates moral hazard by insulating the insured against the cost of healthcare. If the insured has to pay more money, less utilization will occur.

What are some of the key measures of physical health?

Morbidity: disease and disability, as a ratio or proportion of those who have the problem vs. the population at riskIncidence: the number of new cases occurring in the population in a certain period of time Mortality: death rates; crude death rates refer to the total population and are not specific to any age group, but they can be age specific or cause specific Life Expectancy: a prediction of how long a person will live; widely used as a basic measure of health status Disability: measured by looking at "activities of daily living" (ADL) or instrumental activities of daily living (IADL) Births: natality or crude birth rate- the number of live births in a year/total population and is less precise than fertility, because fertility relates to actual births to the sector of the population capable of giving birth. Fertility is the number of live births in a year/number of females aged 15-44. Migration: refers to the geographic movement of populations between defined geographic units and involves a permanent change of residence. Immigration: in-migration Emigration: out migration. Net migration rate = number of immigrants - number of emigrants/total population during the specific period of time being considered

What are the three basic models for structuring national health care systems outside of the U.S.?

National health insurance (NHI), National Health System (NHS), Socialized Health Insurance (SHI)

People who are covered by Medicare have all of their medical bills covered so long as they have both Medicare Part A and Medicare Part B... is that correct?

No, Medicare Part A covers the hospital. Part B is physician services and other outpatient services. How much you pay depends on what plan you pay into. There are still a lot of out of pocket costs the recipient must pay, how much depends on what plan they're on.

Financing

On the front end and describes how society pays for the delivery system; this is necessary to obtain health insurance or to pay for health care services. For most people, their employer finances the insurance for their employees. The government acts as the financier for people in gov health insurance programs.

What are two common high-level overall ways to classify or describe health care institutional structures?

Outpatient facilities where ambulatory care takes place Inpatient facilities which involve an overnight stay or longer

When the Supreme Court voted 7-2 to support the Affordable Care Act (again) and given the Court's decisive rejection of the lawsuit to try and bring it down, what does that likely mean for the future of the law? More importantly, why?

Over the years, the ACA has been weakened financially but not eliminated. The law is here to stay, especially since there is increasing public support for the ACA.

Chronic condition

Persists over time, is not severe, but is generally irreversible. May be kept under control through appropriate medical treatment, but if left untreated it may lead to severe and life-threatening health problems. Ex. Hypertension, asthma, arthritis, heart disease, diabetes.

Primary Care

Point of entry into the delivery system; the point of gatekeeping. Providers serve a role as coordinators of care

What do we have when we integrate the medical model (focusing on treatment) with disease prevention, health-promotion, and a primary-care-based model that produces significant gains in health?

Population Health

Insurance

Protects the insured against financial catastrophes in the event of expensive healthcare services

Payment

Reimbursement to providers for services delivered. Done by insurance companies, third part claims processors.

Acute condition

Relatively severe, episodic (of short duration), and often treatable and subject to recovery. Treatments are generally provided in a hospital. Ex. Sudden interruption of a kidney function, myocardial infarction

What are the problems with employment based health insurance?

Small businesses cannot get group insurance for their employees at affordable rates so they cannot offer their employees' health insurance. In some work settings, participation in health insurance is voluntary. Employers do not pay 100% of the premiums, so employees do not sign up since they cannot afford the premiums.

Community Rating

Spreads the risk among members of a larger population.. Premiums are based on the utilization experience of the entire population covered by the same type of insurance. Same rate regardless of age, gender, or other indicator of health risk. Healthy people subsidize insurance costs for poor risks.

Reinsurance

Stop-loss coverage that self-insured employers purchase to protect themselves against any potential risk of high losses. Bought through an off-shore captive, have less stiff insurance policies. Usually done by large companies with large reserves

What is the "medical loss ratio?"

The % of premium revenue actually spent on medical expenses is termed the MDR. You want a low MDR so that the rest is profit. Insurers use the remainder of the money obtained through premiums for administration, marketing, and profits. Health plans that did not meet the mandates were required to give rebates to enrollees. 85% for large group insurance plans and 80% for individual or small-group plans to pay medical claims.

What were the indicators of the loss of employer-sponsored health insurance during the COVID-19 pandemic?

The State Health Access Data Assistance Center found that 4% of adults aged 18+ (roughly 10 million people) reported losing health insurance coverage since the pandemic began, either because their employee-based coverage ended or they had to cancel coverage to pay for other expenses. This accelerated Medicaid enrollment!

What does the term "surge capacity" mean?

The ability of a health care facility or system to expand its operations to safely treat an abnormally large influx of patients Two types of surge capacity are local/system and community level. Highest final tier of diseaster is under the National Disaster Medical System (NDMS) that directly responds to the needs of an overwhelmed community

Premiums

The amount charges by the insurer to insure against specified risks. Premiums can vary depending on the plan selected by the employee

Deductible

The amount the insured must first pay each year before any benefits are payable by the plan.

Self-insurance

The employer acts as its own insurer instead of obtaining insurance through an insurance company. Rather than paying insurers a dividend to bear the risk, many employers assume the risk by budgeting a certain amount to pay medical claims incurred by employees. Large businesses typically choose this route. Gives employers more control. Self-insured employers can protect themselves against the risk of high losses with reinsurance

National health insurance (NHI)

The government finances health care through general taxes, but the actual care is delivered by private providers. NHI requires tighter consolidation of the financing, insurance, and payment functions coordinated by the government. Delivery is characterized by detached private arrangements

Delivery

The provision of health care services by providers. Physicians, hospitals, nursing homes, diagnostic center, etc

What is presently one of the greatest challenges to the U.S. health care system?

The quest to control costs while still meeting the increasing healthcare demands of an aging population, a population with more chronic diseases and comorbidities.

Your textbook asserts that there will probably always be a large number of uninsured people in the United States? Why is that?

The textbook asserts this because they claim that there will always be undocumented immigrants, young+healthy individuals who choose not to buy insurance, and those who do not qualify for medicaid based on income.

In the U.S., health care reform generally refers to the attempt to expand health insurance to cover who?

The uninsured

What is "individual private health insurance?"

These are individually purchased private health insurance (nongroup plans) which have been a relatively small but important source of coverage for some Americans. Examples of those covered by this plan are family farmers, early retirees, self-employed, and employees of businesses that do not offer insurance. Risk indicated by each individuals health status and demographics are taken into account, so high-risk individuals are often unable to obtain privately purchased health insurance (this was eliminated by the ACA). In 2015, about 7% of the US population had nongroup private insurance.

The key players in the system have traditionally been physicians, administrators, of health service institutions, insurance companies, large employers, and the government. How do these entities interact to create some of the U.S. System's problems and why?

These entities all have their own economic interests they want to protect so when they interact, problems arise which makes it difficult to achieve comprehensive reform. Tragedy of the commons: occurs when you have a group of entities that are working together but each one is trying to maximize their individual gains at the expense of the whole/others; this term is generally for providers and pharmaceutical companies

What would an example be of the supply of health care services being curtailed when reimbursement is cut?

This happens frequently at the state level with medicaid. When medicaid reimburses well for OB services, a lot of hospitals want to be in the business of delivering babies. When medicaid cuts reimbursement, hospitals do not want to offer these services/limit them

What is defensive medicine?

To protect against the possibility of litigation and legal risks, which is very prevalent in America, practitioners may prescribe additional diagnostic tests, schedule return visits, and maintain copious documentation. These efforts can be costly and inefficient.

When the ACA was passed there were requirements that everyone had to be covered by some type of policy, but later modifications and legislative action eliminated the so-called "mandate." What impact would that have in the long run on the efficacy of the ACA (or any insurance product for that matter)?

Ultimately, it would cause the plan to fail bc once the mandate is eliminated, that would mean that the risk pool would skew as only those who are likely to need insurance would buy it, thus making the financial model unsustainable.

Country that has NHS?

United Kingdom

Secondary Care

Usually short term, maybe sporadic Consultation from a specialist to provide a level of care the PCP is not able to provide.

Utilization and Crude Measures of it

Utilization: the consumption of healthcare services and the extent to which healthcare services are used (ex: Access to primary care services, utilization of primary care/specific inpatient services) Average daily census = total number of inpatient days in a given time period/number of days in the same time period Occupancy rate = total number of inpatient days in a given time period/total number of available beds in the same time period or average daily census/total number of beds in the facility Average length of stay = total number of inpatient days during a given time period/total number of patients served during the same time period.

National Health System (NHS)

Where the central government finances with tax revenues (NHI), but also employs most of the providers and owns/operates most of the hospitals.

Can both Medicare and Medicaid cover a person in the U.S. system at the same time? What would a good example of that be?

Yes. Those with Medicare and Medicaid are dually eligible and the most common place to find this is in nursing homes.

Copayment

flat amount the insured must pay each time health services are received

Who does medicaid serve?

indigent, those in need

Risk Rating

premiums are determined by the actuarial assessment of risk that adjusts premiums to reflect health status. there are three methods of risk rating: experience, community, and adjusted community

Who does medicare serve?

program for the elderly and certain disabled individuals, children with end stage renal disease

What is underwriting?

systematic technique for evaluating, selecting (or rejecting), classifying and rating risks. Medical underwriting, for example, takes into account the health status of people to be insured.