The Healthcare System Chapters 1-6
In general, who are allied health professionals? What role do they play in the delivery of health services?
The term allied health is used loosely to categorize several different types of professionals in a vast number of health-related technical areas. Among these professionals are technicians, assistants, therapists, and technologists. These professionals receive specialized training, and their clinical interventions complement the work of physicians and nurses. Certain professionals, however, are allowed to practice independently, depending on state law.
health care
The treatment of illness and the maintenance of health
What are Medicare trust funds? Discuss the current state and the future challenges faced by the Medicare trust funds. What main factors pose these challenges?
There are two main trust funds under Medicare. The HI trust fund provides the money pool for Part A services. The SMI trust fund provides the money pool for Parts B and D. The current state of these trust funds are in a state of deficit. Payment cuts and enrollment in MCOs are made to slow down the rate of growth in expenditures. The three main factors concerning future challenges are: (1) the cost of delivering healthcare continues to grow at a rate faster than the rate of inflation in the general economy, (2) an aging population will consume a greater quantity of health care services, and (3) the workforce is shrinking, and wage increases to support payroll tax revenues are smaller than the rise of medical inflation
How can health care administrators and policymakers use the various measures of health status and service utilization? Use examples to illustrate your answer.
They could use measures of health status to monitor the incidence of a disease and decide if the health promotion and disease prevention in that area is successful. They can use measures of health utilization to decide if the number of providers in the area are contributing to a high incidence of a disease.
Which main role does the government play in the U.S. health services system?
They determine public-sector expenditures and reimbursement rates for services provided to Medicare, Medicaid, and CHIP beneficiaries. Formulates standards of participation through health policy and regulation, meaning providers must comply with the standards established by the government to be certified to provide services to these beneficiaries. Certification standards are regarded as minimum standards of quality in most sectors of the health care industry. They finance 48% of total health care expenditures.
Why is it important for health care managers and policymakers to understand the intricacies of the health care delivery system?
They must understand the macro environment in which they make critical planning and management decisions. Such decisions will ultimately affect the efficiency and quality of services delivered.
From the standpoint of health insurance, what were the main accomplishments of the affordable care act?
Through the Affordable care act more than 20 million people got insured. There were lesser uninsured people in America compared to 2014, there were less number of people left uninsured as the affordable care act was costed less than what American people had to pay. American people have more options to choose from hospitals and doctors compared to the past where people had little choice of hospitals and doctors. This law has made people financially stable as they have to spend lesser on medical insurance than before. Through the affordable care act the US government able to levy more tax through medical insurance on rich and financial freedom to poor, bridging the gap between poor and rich. The Affordable Care act had given the Small Business Health Options Program to small business owners to provide health and dental insurance to their employees. They can get this insurance through private insurance company at lower cost.
Which conditions during the World War II period lent support to employer-based health insurance in the United States?
To control high inflation in the economy during the World War II period, Congress imposed wage freezes. In response, many employers started offering health insurance to their workers in lieu of wage increases.-In 1948, the US Supreme Court ruled that employee benefits, including health insurance, were a legitimate part of union-management negotiations. Health insurance then became a permanent part of employee benefits in the postwar era.-In 1954, Congress amended the Internal Revenue Code to make employer-paid health coverage nontaxable. In economic value, employer-paid health insurance was equivalent to getting additional salary without having to pay taxes on it, which provided an incentive to obtain health insurance as an employer-furnished benefit.
Provide a brief description of the roles and responsibilities of health services administrators.
Top-level administrators provide leadership and strategic direction, work closely with the governing boards, and are responsible for an organization's long-term success. They are responsible for operational, clinical, and financial outcomes of their entire organization. Middle-level administrators may have leadership roles for major service centers, such as outpatient, surgical, and nursing services, or they may be departmental managers in charge of single departments, such as diagnostics, dietary, rehabilitation, social services, environmental services, or medical records. Their jobs involve major planning and coordinating functions, organizing human and physical resources, directing and supervising, operational and financial controls, and decision making. They often have direct responsibility for implementing changes, creating efficiencies, and developing new procedures with respect to changes in the health care delivery system. Entry-level administrators may function as assistants to middle-level managers. They may supervise a small number of operatives. For example, their main function may be to oversee and assist with operations critical to the efficient operation of a departmental unit."
In the context of globalization in health services, what main economic activities are discussed in this chapter?
Transnational movement and exchange of goods, services, people and capitol. Telemedicine, medical tourism, and demand for health care workers in other countries.
global budget
Used to control costs in centrally managed systems. System wide healthcare expenditures are budgeted. Resources are allocated within the budgetary limits. Availability of services and payments to providers are subject to such budgetary constraints.
Provide a brief overview of how technology influences the quality of medical care and quality of life.
When advanced techniques can provide more precise medical diagnoses than before, quicker and more complete cures than previously available, or reduce risks in a cost-effective manner, the result is improved quality. Technology can also provide new remedies where none existed before. More effective, less invasive, and safer therapeutic and preventive remedies can increase longevity and decrease morbidity."
moral hazard
When the act of insuring an event increases the likelihood that the event will happen, i.e.- insured people using more health care services.
What is the difference between national health insurance (NHI) and a national health system (NHS)?
With NHI, the government finances health care through general taxes, but the care is delivered by private providers. Tighter consolidation of financing, insurance and payment features of quad-function model. Delivery detached private arrangements. With NHS, in addition to financing a tax-supported NHI program, the government manages the infrastructure for delivery of medical care. Government operates most of the country's medical institutions. Most health care providers are government employees or tightly organized in a publicly managed infrastructure. Requires tighter consolidation of all four functions.
single-payer system
a national health care program in which the financing and insurance functions are taken over by the federal government (NHS)
holistic medicine
an approach to health care that emphasizes prevention of illness and takes into account a person's entire physical and social environment
chronic condition
an illness, injury, or other condition that is expected to last for a long time or which has developed slowly over a period of time
third party
an intermediary between patients and providers that carry out the functions of insurance and payment for health care delivery.
Which type of illegal activities constitute health care fraud and abuse?
billing for services not provided, delivery of unnecessary services, providing compensation to others or receiving kick-backs for participating in a fraud scheme, and misrepresentation of services to receive higher reimbursement.
package pricing
bundling of fees for an entire package of related services
risk factors
characteristics or behaviors that increase the likelihood of developing a medical disorder or disease
primary care
continual basic and routine care
administrative costs
costs associated with billing, collections, bad debts, and maintaining medical records.
mortality
death
medical model
delivery of health care that places its primary emphasis on the treatment of disease and relief of symptoms instead of prevention of disease and promotion of optimum health
holistic health
emphasizes the well-being of every aspect of what makes a person whole and complete
social justice
justice in terms of the distribution of wealth, opportunities, and privileges within a society.
emigration
movement of individuals out of an area
migration
movement of people from one place to another
environment
one of the factors of the epidemiology triangle, which is external to the host; it includes the social, physical,cultural, and economic aspects.
agent
one of the factors of the epidemiology triangle, which must be present for an infectious disease to occur.
free market
patients and providers act independently, with patients able to choose services from any provider. Prices are governed by the free and unencumbered interaction of the forces of supply and demand.
activities of daily living (ADLs)
personal daily care tasks, including bathing, skin, nail, and hair care, walking, eating and drinking, mouth care, dressing, transferring, and toileting
Why is there a geographic maldistribution of the physician labor force in the U.S.?
physicians are more likely to concentrate in metropolitan and suburban areas rather than in rural and inner-city areas
utilization
quantity of health care consumed
acute condition
rapid onset, a severe course, and a relatively short duration
instrumental activities of daily living (IADLs)
tasks necessary to conduct the business of daily life and also requiring some cognitive competence, such as telephoning, shopping, food preparation, housekeeping, and paying bills
need
the amount of medical care that medical experts believe a person should have to remain or become healthy.
Bioterrorism
the deliberate spread of pathogenic organisms into a community to cause widespread illness, fear, and panic
public health
the practice of protecting and improving the health of people in a community
demand
the quantity of health care purchased
natality
the ratio of live births in an area to the population of that area
quality of life
the standard of health, comfort, and happiness experienced by an individual or group.
environmental health
the study of how environmental factors affect human health and quality of life
population at risk
those in the population who are susceptible to a particular disease or condition
uninsured
those without private or public health insurance coverage
Why did medicine have a domestic, rather than professional, character in the preindustrial era? How did urbanization change that?
• Medicine had a domestic character because Americans neglected research in basic sciences in favor of applied science. Additionally, emphasis of medical treatment was on natural history and conservative common sense.• Urbanization increased the reliance on specialized skills. People were further from families (having moved from rural to urban settings), women began working outside the home. Opportunity costs to consult with doctors decreased. Travel was faster, phones could be used. PG.97-98
On what basis were the elderly and the poor regarded as vulnerable groups for whom special government-sponsored programs needed to be created?
• The elderly & poor could not afford the cost of care• The elderly had higher incidences and prevalence of disease. Provision of charity care led to private payers being charged more for cost-shifting/cross subsidization
How did the emergence of general hospitals strengthen the professional sovereignty of physicians?
"hospitals became the core around which the delivery of medical services was organized. Thus, development of hospitals as the center for the practice of scientific medicine and the professionalization of medical practice became closely intertwined."
Provide a general overview of the Affordable Care Act. What is the main goal?
"rolled out gradually starting in 2010 when insurance companies were mandated to start covering children and young adults below the age of 26..... mandate for employers to provide health insurance, which is postponed until 2015....requires that all US citizens and legal residents must be covered by either public or private insurance. The law also relaxed standards to qualify additional numbers of people for Medicaid.... Federal subsidies have been made available to people with incomes up to 400% of the federal poverty level to partially offset the cost of health insurance....The law mandates insurance plans to cover a variety of services referred to as "essential health benefits."...by its own design, the ACA would fail to achieve universal cover-age that would enable all citizens and legal residents to have health insurance. "The main goal of the ACA is to increase access to health care and make it more affordable, mainly for those who were previously uninsured."
According to the Institute of Medicine, what are the four main components of a fully developed electronic health record (EHR) system?
(1) Collection and storage of health information on indi-vidual patients over time; (2) immediate electronic access to person- and population-level information by authorized users; (3) availability of knowledge and decision support that enhances the quality, safety, and efficiency of patient care; (4) support of efficient processes for health care delivery."
tertiary prevention
-aims to prevent the long-term consequences of a chronic illness or disability and to support optimal functioning -examples: prevention of pressure ulcers as complication of a spinal cord injury; promoting independence for the client who has traumatic brain injury
market justice
A distributional principle according to which health care is most equitably distributed through the market forces of supply and demand, rather than government interventions.
Medicare
A federal program of health insurance for persons 65 years of age and older, or certain disabled individuals.
system
A group of parts that work together as a whole
Medicaid
A health care payment program sponsored by federal & state governments for the indignant.
Why does containment remain an elusive goal in U.S. health services delivery?
A lack of system-wide planning, direction, and coordination leading to a complex and inefficient system. The system as a whole doesn't lend itself to standard budgetary methods of cost control. Individual and corporate entities within a primarily entrepreneurial system seek to manipulate financial incentives to their own advantage without regard to the system as a whole.
community health assessment
A method used for conducting broad assessments of populations at a local or state level.
What is the role of heath risk appraisal in health promotion and disease prevention?
A program of health promotion and disease prevention is built on three main principles: (1) An understanding of risk factors associated with host, agent, and/or environment. Risk factors and their health consequences are evaluated through a process called health risk appraisal. Only when the risk factors and their health consequences are known can interventions be developed to help individuals adopt healthier lifestyles."
What is managed care?
A system of health care delivery that seeks to achieve efficiency by integrating the four functions of health care delivery. It employs mechanisms to control (manage) utilization of medical services. It determines the price of services, and consequently how much the providers are paid.
managed care
A system that combines the financing and the delivery of appropriate, cost-effective health care services to its members.
What is socialized health insurance (SHI)?
A system where government-mandated contributions from employers and employees finance healthcare. Private not-for-profit insurance companies, called sickness funds, are responsible for collecting the contributions and paying hospitals and physicians.
epidemic
A widespread outbreak of an infectious disease that spreads rapidly and affects many individuals in a population.
What are the major methods of reimbursement for outpatient services?
A. Fee-for-service reimbursement pays a separate amount for each identifiable and individually distinct unit of service. B. Charges may be based on a set of related bundled services.
Why is it important to achieve a balance between clinical efficacy and economic worth (cost effectiveness) of medical treatments?
Achieving a balance between efficacy and economic worth will require a change in the American mindset, which will not be forth-coming in the near future."In the United States, the predominant fear is that an organization risks being sued if it denies access to treatments that are known to be medically effective even when their cost effectiveness is questionable (Bryan et al. 2009). With-out malpractice reform, overuse of technology will continue to rack up costs. At some point, the United States may have no choice but to restrict the use of medical technologies on the basis of their economic worth."
supply-side rationing
Also called planned rationing because the government, faced with limited resources, makes deliberate attempts, often referred to as "health planning," to limit the availability of healthcare services, particularly those beyond the basic level of care.
enrollee
An individual enrolled in a health plan and therefore entitled to receive health services the plan provides.
provider
An individual or company that provides medical care and services to a patient or the public.
Which factors have been responsible for the low diffusion and low use of telemedicine?
An unclear or unidentified need for certain types of telemedicine services, uncertain reimbursement policies, absence of interstate licensure reciprocity, lack of universal access to necessary technology, concerns about patient confidentiality, and limited precedent regarding liability issues.
provider-induced demand
Artificial creation of demand by providers that enables them to deliver unneeded services to boost their incomes.
What is the primary reason for employers to purchase insurance plans to provide health benefits to their empolyees?
As a fringe benefit, but also to reduce the number of sick days and absences from work due to illness.
Why is the U.S health care market referred to as "imperfect"?
Because prices are set by agencies external to the market, they are not governed by the unencumbered forces of supply and demand like it would be in a free market.
subacute condition
Between acute and chronic but has some acute features. Subacute conditions can be post acute requiring further treatment after a brief stay in the hospital. Examples include ventilator and head trauma care.
Iatrogenic illnesses (or injuries)
Caused by the process of health care.
Provide brief descriptions of clinical information systems, administrative information systems, and decision support systems in health care delivery.
Clinical information systems involve the organized processing, storage, and retrieval of information to sup- port patient care delivery. Ex: EMR Administrative information systems assist in carrying out financial and administrative support activities, such as payroll, patient accounting, billing, materials management, budgeting and cost control, and office automation. Decision support systems provide information and analytical tools to support managerial and clinical decision making. Two types: Managerial decision support systems can be used to forecast patient volume, project staffing requirements, and schedule patients to optimize utilization of patient care and surgical facilities. Clinical decision support systems (CDSS) encompass a range of applications, from general references, through treatment protocols, to recommendations that are tailored to a patient's unique clinical data."
reimbursement
Compensation or repayment for healthcare services to providers
What is the relationship between reimbursement cuts and cost shifting? How do hospitals react in different markets to cuts in reimbursement?
Cost shifting is used when reimbursement cutsoccur. Providers resort to cost shifting by charging extra to payers who do not exercise strict cost controls.Hospitals in less competitive marks raise prices to private insurers when faced with the short falls between Medicare payments and their projected costs.
Describe the major types of health service professionals (physicians, nurses, dentists, pharmacists, physician assistants, nurse practitioners, certified nurse midwives)including their roles, training, practice requirements, and practice settings.
DENTISTS 1. Dentists are the major providers of dental care• To diagnose and treat problems related to the teeth, gums and tissues of the mouth• Must have graduated from accredited dental school that awards a Doctor of Dental Surgery (DDS) or Doctor of Dental Medicine (DMD) degree and successful completion of both written and practical examinations. PHARMACISTS 1. Pharmacists dispense medicines prescribed by physicians, dentists, and podiatrists, and provide consultation on the proper selection and use of medicines• Must have graduated from an accredited pharmacy program that awards a Bachelor of Pharmacy or Doctor of Pharmacy (PharmD) degree, successful completion of state board examination, and practical experience or completion of a supervised internship. NURSES 1. Constitute the largest group of health care professionals-> major caregivers of sick and injured patients, addressing their physical, mental, and emotional needs 2. Two basic levels of licensed nurses: • RN (Registered Nurses) a) Three avenues of RN education/preparation:- Associate degree (ADN) that takes 2-3 years and are offered by community and junior colleges, a diploma program that takes 2-3 years and are offered by hospitals, or a bachelor of science in nursing (BSN) degree that takes 4-5 years and are offered by colleges and universities• LPN/LVNs (Licensed practical nurses)a) complete a state-approved program in practical nursing and take a national written examination b) nursing programs last about one year and include classroom study as well as supervised clinical practice 3. Advanced practice nurses (APNs):• Have attained education and training beyond the RN level.• Four main categories: a) Clinical nurse specialists. Work in hospitals (vs home health, clinics, or nursing homes). Specialize in fields such as cardiac care, oncology, neonatal care, psychiatric care. b) Certified Registered Nurse Anesthetists. Trained to manage anesthesia during surgery. c) Nurse Practitioners. Trained to provide primary care services, often independent of physicians. d) Certified Nurse Midwives. Deliver babies and man-age the care of mothers and newborns before, during, and after delivery 4. Nurses work in a variety of settings • Hospitals, nursing homes, private practice, ambulatory care centers, community and migrant health centers, emergency medical centers, MCOs, work sites, government and private agencies, clinics, schools, retirement communities, rehabilitation centers, and as private-duty nurses in patient's homes PHYSICIANS 1. Play a central role in delivery of health services by evaluating patients and health conditions, diagnosing abnormalities, and prescribing treatments. Some are engaged in medical education and research. 2. State required license which includes graduation from an accredited medical school that awards MD or DO degrees; successful completion of a licensing exam, completion of a supervised internship/residency program. 3. Can be primary care physicians (generalists), or go into a specialty position. Work in many different settings from primary practices to trauma centers.
How does technology-driven competition lead to greater levels of technology diffusion? How does technological diffusion, in turn, lead to greater competition? How does technology-driven competition lead to duplication of services?
Despite the fact that health care delivery in the United States is not characterized by true market conditions (see Chapter 1), providers of health care services do compete. Paradoxically, however, competition in health care often increases costs. Hospitals, as well as outpatient centers, compete to attract insured patients. Well insured patients look for quality, and institutions create perceptions of higher quality by acquiring and advertising state-of-the-art technology. Specialists have also been responsible for stimulating com- petition. Many physicians, for example, have opened their own specialty hospitals, diagnostic imaging facilities stocked with next-generation scanners, and same-day surgery centers that have hotel-like facilities—these developments have fueled a de facto medical arms race."
Discuss the roles of efficacy, safety, and cost effectiveness in the context of health technology assessment.
Efficacy or effectiveness is defined simply as health benefit derived from the use of technology. Safety considerations are designed to protect patients against unnecessary harm from technology. As a primary benchmark, benefits must outweigh any negative consequences; however, negative consequences cannot always be foreseen. Cost efficiency (or cost effectiveness) is a step beyond the determination of efficacy. Whereas efficacy is concerned only with the benefit derived from the technology, cost effectiveness evaluates the additional (marginal) benefits derived in relation to the additional (marginal) costs incurred. Technology assessment, or more specifically, health technology assessment (HTA), refers to "any process of examining and reporting properties of a medical technology used in health care, such as safety, effectiveness, feasibility, and indications for use, cost, and cost-effectiveness, as well as social, economic, and ethical consequences, whether intended or unintended" (Institute of Medicine 1985). HTA seeks to contribute to clinical decision making by providing evidence about the efficacy, safety, and cost effectiveness of medical technologies. It also informs decision makers, clinicians, patients, and the public about the ethical, legal, and social implications of medical technologies (Lehoux et al. 2009)."
secondary prevention
Efforts to limit the effects of an injury or illness that you cannot completely prevent.
primary prevention
Efforts to prevent an injury or illness from ever occurring.
defensive medicine
Excessive medical tests and procedures performed as a protection against malpractice lawsuits, otherwise regarded as unnecessary.
What is the difference between experience rating and community rating?
Experience rating refers to a group's own medical claims experience, premiums differ from group to group because different groups have different risks. Community rating risk is spread among members of a larger population. Premiums are based on the utilization experience of the entire population covered by the same type of health insurance. Same rate applies to everyone regardless of age, gender, etc.
health determinants
Factors that contribute to the general well-being of individuals and population.
Name the four basic components of the U.S. health care delivery system. Which role does each play in the delivery of health care?
Financing- medical services and health care have to be paid for and funded by someone. If someone can't afford services, the delivery of health care is halted. Insurance- protects the insured from financial catastrophe. Regulates payments to providers allowing for delivery of health care. Delivery- you must have providers to deliver health care services. Lack of providers hinder delivery. Payment- How services are paid for affect delivery. Insurance providers determine premiums and how much reimbursement is valid for a certain service.
How did the organized medical profession manage to remain free of control by business firms, insurance companies and hospitals until the latter part of the 20th century?
For a long time, physicians' ability to remain free of control from hospitals and insurance companies remained a prominent feature of American medicine.Hospitals and insurance companies could have hired physicians on salary to provide medical services, but individual physicians who took up practice in a corporate setting were castigated by the medical profession and pressured to abandon such practices. In some states, courts ruled that corporations could not employ licensed physicians without engaging in the unlicensed practice of medicine, a legal doctrine that became known as the "corporate practice doctrine" (Farmer and Douglas 2001).Independence from corporate control enhanced private entrepreneurship and put American physicians in an enviable strategic position in relation to hospitals and insurance companies. Later, a formally organized medical profession was in a much better position to resist control from outside entities
What impact has technology had on access to medical care?
Geography is an important factor in access to technology. If a technology is not physically available to a patient population living in remote areas, access is limited. Geographic access can improve for many technologies by providing mobile equipment or by employing new communications technologies to allow remote access to centralized equipment and specialized personnel. Mobile equipment can be transported to rural and remote sites, making it accessible to those populations.
Why is there an imbalance between primary care and specialty care in the United States?
Growth of new medical technology. Because the population increases at a significantly slower rate than technological advancements, the gap between primary and specialty care workforces continues to expand.Higher incomes of specialists relative to PCPs have also contributed to an oversupply of specialists.Specialists also have more predictable work hours and enjoy higher prestige among their colleagues and the public at large.The medical education environment in the United States is organized according to specialties and controlled by those who have achieved leadership positions by demonstrating their abilities in narrow scientific or clinical areas."
What are the main provisions of HIPAA with regard to the protection of personal health information? What provisions were added to HIPAA under the HITECH Act?
Health Insurance Portability and Accountability Act (HIPAA) of 1996 makes it illegal to gain access to a patient's personal health information (PHI) for reasons other than health care delivery, operations, and reimbursement. HIPAA legislation mandated strict controls on the transfer of personally identifiable health data between two entities, provisions for disclosure of protected information, and penalties for violation (Clayton 2001). In January 2013, the DHHS issued revisions to HIPAA in conjunction with the HITECH law. HITECH Act earmarked an estimated $19 billion in direct grants and financial incentives to promote the adoption of EHRs by hospitals and physicians (Wang et al. 2013)."
What role does an IT department play in a modern health care organization?
Health care IT includes medical records systems to collect, transcribe, and store clinical data; radiology and clinical laboratory reporting systems; pharmacy data systems to monitor medication use and avoid errors, adverse reactions, and drug interactions; scheduling systems for patients, space (such as surgery suites), and personnel; and financial systems for billing and collections, materials management, and many other aspects of organizational management."
universal coverage
Health insurance coverage for all citizens.
Discuss the intermediary role of insurance in the delivery of health care.
Health insurance is the primary means of ensuring access. Insurance decides what services are covered and how much providers are paid for services.
Generally speaking, why is medical technology more readily available and used in the United States than in other countries?
High-tech procedures are more readily available in the United States than in most other countries, and little is done to limit the expansion of new medical technology.The United States also has more high-tech equipment, such as magnetic resonance imaging (MRI) and computed tomography (CT) scanners, available to its population than most other countries. Other nations have tried to limit, mainly through central planning, the diffusion and utilization of high-tech procedures to control medical costs.
What is meant by health care financing in its broad sense? How does financing affect the health care delivery system?
In broad terms, financing includes the concepts of financing, insurance, and payment. In basic terms, financing enables people to obtain health insurance. The payment function determines reimbursement and undertakes the actual payment for services received by the insured. The key impact of financing is in determining access to health care services. Thus, the demand for health care is directly related to its financing. Financing also influences supply-side factors, such as how much health care is produced. Financing eventually affects the total healthcare expenditures incurred by a health delivery system.--------------------------------------------------short answer: health care financing, in its broad sense, deals with the concepts of financing, insurance, and payment. The key impact of financing on the health care delivery system involves determining the access to health care services.
What measures have been or can be employed to overcome problems related to physician maldistribution and imbalance?
In recent years, reimbursement systems designed to increase payments to PCPs have been implemented, but wide disparities between the incomes of generalists and specialists continue
Which factors explain why the demand for the services of a professional physician was inadequate for the preindustrial era? How did scientific medicine and technology change that?
In rural areas, families and communities were accustomed to treating the sick, often using folk remedies passed from one generation to the next. It was also common to consult published books and pamphlets. Many families could not afford to pay for medical services. Advancement in science and technology was one reason for the increased demand of medical services. Advances in bacteriology, antiseptic surgery, anesthesia, immunology, diagnostic techniques, and new drugs gave medicine an aura of legitimacy and complexity. Scientific medicine and technology increased people's reliance on physician's professional judgment. Laypeople were no longer competent to provide medical care. Professional help was likely to do more for the patient than what folk remedies could do
Explain how contract practice and prepaid group practice were the prototypes of today's managed care plans
Industries operating contract practice plans either hired physicians on salary or contracted with independent physicians and hospitals at a flat capitated rate per worker per month. These features are found in certain managed care plans today. Prepaid group practice also provided comprehensive services for a capitated fee. Later, health maintenance organizations were modeled after prepaid health plans. Managed care organizations today attempt to combine the efficiencies of contract and group arrangements with the objective of delivering comprehensive healthcare services at predetermined costs
Distinguish between information technology (IT) and health informatics.
Information technology (IT) deals with the transformation of data into useful information. IT involves determining data needs, gathering appropriate data, storing and analyzing the data, and reporting the information in a format desired by its end users. Health informatics is broadly defined as the application of information science to improve the efficiency, accuracy, and reliability of health care services. Health informatics requires the use of IT but goes beyond IT by emphasizing the improvement of health care delivery. For example, designing CDSSs falls in the domain of health informatics. Applications of informatics are also found in electronic health records and telemedicine."
Discuss the general concept of insurance and its general principles. Describe the various types of private health insurance options, pointing out the differences among them.
Insurance is a system/service that essentially protects the insured against risks. The general principles of risk are as follows (1) risk is unpredictable for an individual, (2) risk can be predicted for a group or population with some degree of accuracy, (3) by gathering resources, insurance can shift the risk from an individual to the group, and (4) equitable losses are shared by all members. The types of private health insurance options are group insurance, self-insurance, individual private insurance, and MCOs. Group insurance: an insurance that covers a defined group of people Self-insurance: insurance of one's interests by maintaining a fund to cover possible losses rather than by purchasing an insurance policy. Individual private insurance: determines premium price and eligibility based on risk calculated by an individual's health status and demographic Managed Care Plans: consists of HMOs and PPOs
What are the major differences between Healthy People 2020 and the previous Healthy People initiatives?
It includes multiple new topic areas to its objectives list, such as adolescent health, genomics, global health, health communication and health information technology and social determinants of health.
Discuss the significance of an individual's quality of life from a health care delivery perspective.
It indicates how satisfied a person was with his or her experiences while receiving health care. Includes comfort factors, respect, privacy,decision-making autonomy, and attention to personal preferences. These are now regarded as rights that patients can demand during any type of health care encounter.
Briefly describe the Medicare Advantage Program.
It is also called Medicare part C, and provides some additional choices of health plans wit the objective of channeling a greater number of beneficiaries into managed care plans. PG. 236
What are the two main objectives of a health care delivery system?
It must enable all citizens to obtain needed healthcare services. It must ensure that services are cost-effective and meet certain established standards of quality.
Discuss the concept of value-based purchasing, as required by the ACA.
Linking provider payments to improved performance by health care providers. This form of payment holds health care providers accountable for both the cost and quality of care they provide. It attempts to reduce inappropriate care and to identify and reward the best-performing providers.
What are some of the ethical issues surrounding the development and use of medical technology?
MCOs, and physician advocacy institutions often act and advocate out of their own self-interests. They often claim that quality would deteriorate and/or harm would ensue unless new innovations are funded. Biases might also arise in studies funded by sources that have a financial stake in the results. Such concerns have stimulated interest in developing standards for assessments, perhaps under the aegis of a govern-mental body. Public and private insurers face the problem of deciding whether to cover novel treatments.The question arises as to whether society should even bear the cost of infertility treatments, genetic tests, and lifestyle remedies that do not affect people's health and longevity.Therapies classified as experimental are, generally, not covered by insurance. Availability of and payment for treatments considered experimental may be needed by critically ill patients who could possibly benefit from the treatment.that ethical clinical research must fulfill seven requirements: (1) The research must have social or scientific value for improving health or enhancing knowledge. (2) The study must be scientifically valid and methodologically rigorous. (3) The selection of subjects in clinical trials must be fair.(4) The potential benefits to patients and the knowledge gained for further scientific work must out-weigh the risks. (5) Independent review of the research methods and findings must be conducted by unaffiliated individuals.(6) Informed, voluntary consent must be obtained from subjects. (7) The privacy of enrolled subjects must be protected, they must be offered the opportunity to with-draw, and their well-being must be maintained throughout the trial."
Describe how health care is rationed in the market justice and social justice systems.
Market Justice: "limitations to obtaining health care are referred to as "rationing by ability to pay" (Feldstein 1994), demand-side rationing , or price rationing" Under social justice, the government decides how technology will be dispersed and who will be allowed access to certain types of costly high-tech services, even though basic services may be available to all. The government engages in supply-side rationing , which is also referred to as planned rationing , or non-price rationing. In social justice systems, the government uses the term "health planning" to limit the supply of health care services, although the limited resources are often more equally dispersed throughout the country than is generally the case under a market justice system. It is because of the necessity to ration health care that citizens of a country can be given universal coverage but not universal access."
Briefly describe the concepts of market justice and social justice. In which ways do the two principles complement each other, and in which ways are they in conflicting the U.S. system of health care delivery?
Market justice leaves the fair distribution of health care up to the market forces in a free economy. medical care and its benefits are distributed based on people's willingness and ability to pay. Social Justice depicts that the equitable distribution of health care is a societal responsibility, which is best achieved by letting the government take over the production and distribution of health care. Neither one of them exists in the health care system today. They both agree people should get what they deserve, but that varies between the two. (chart on PG. 77) The two contrasting principles complement each other with employer-based health insurance for most middle-class working Americans (market justice) and publicly financed Medicare, Medicaid, and CHIP coverage for certain disadvantaged groups (social justice). Market and social justice principles create conflicts when health care resources are not uniformly distributed throughout the United States, and there is a general shortage of primary care physicians (discussed in Chapter 4). Consequently, in spite of having public insurance, many Medicaid-covered patients have difficulty obtaining timely access, particularly in rural and inner-city areas. In part, this conflict is created by artificially low reimbursement from public pro-grams whereas reimbursement from private payers is more generous.
Discuss with particular reference to the roles of a) organized medicine, b) the middle class, and c) american beliefs and values, why reform efforts to bring in national health insurance have historically been unsuccessful
Matters related to health and welfare were typically left to state and local governments, and as a general rule, these levels of government left as much as possible to private and voluntary action. Also in 1920, the AMA's House of Delegates approved a resolution condemning compulsory health insurance that would be regulated by the government (Numbers 1985). The main aim of this resolution was to solidify the medical profession against government interference. Dominance of private institutions of health care delivery was seen to be inconsistent with national financing and payment mechanisms.The insurance industry feared losing the income it derived from disability insurance, some insurance against medical services, and funeral benefits* (Anderson 1990). The pharmaceutical industry feared the government as a monopoly buyer, and retail pharmacists feared that hospitals would establish their own pharmacies under a government-run national health.Union leaders were afraid they would transfer over to the government their own legitimate role of providing social benefits, thus weaken-ing the unions' influence in the workplace. Organized labor was the largest and most powerful interest group at that time, and its lack of support is considered instrumental in the defeat of national health insurance (Anderson 1990). The American value system has been based largely on the principles of market justice. when a government- controlled medical plan was compared to private insurance, polls showed that only 12% of the public favored extending Social Security to include health insurance (Numbers 1985). During this era of the Cold War,* any attempts to introduce national health insurance were met with the stigmatizing label of socialized medicine, a label that has since become synonymous with any large-scale government-sponsored expansion of health insurance or intrusion in the private practice of medicine.National health care program might be ripe. Wofford's call for national health insurance was widely supported by middle-class Pennsylvanians. Election results in other states were not quite as decisive... avoiding tax increases took priority over expanding health insurance coverage and caused the demise of Clinton's health care reform initiatives."
crude rates
Measures referring to the total population; they are not specific to any age groups or disease categories.
Which particular factors that earlier may have been somewhat weak in bringing about national health insurance later led to the passage of Medicare and Medicaid?
Medicaid and Medicare were designed to cover only the most vulnerable populations. The proposals did not re-engineer how the majority of the Americans would receive health care. The growing elderly population was becoming a politically active force among middle-class Americans.
Why did the professionalization of medicine start later in the United States than in some Western European nations?
Medical practice was in disarray early on - it was informal, unregulated and had no existing standards for care• Medical procedures were primitive (e.g., bloodletting) and there was little science to back things up• An institutional core was missing - there were very few hospitals before 1800• Demand was unstable. Very few physicians were rural; most were in big cities and opportunity cost to get to physicians was high (travel, missed work, etc.)• Medical education was substandard. It was typical to have an apprenticeship rather than a formal education
Medical technology encompasses more than just sophisticated equipment. Discuss.
Medical technology can include information technology, and health informatics such as Clinical information systems, administrative information systems, decision support systems, and electronic health records and systems. All of these things help improve the efficiency, accuracy, and reliability of health care services.
What is Medicare Part A? Discuss the financing and cost-sharing features of Medicare Part A. What benefits does Part A cover? What benefits are not covered?
Medicare A is hospital insurance. Both employers and employees finance it through payroll taxes .Benefits of Part A:Inpatient hospital care is allowed per benefit period (maximum of 90 days). Medicare-certified SNF, subsequent to inpatient hospitalization are covered for at least 3 consecutive days (up to 100 days of care), not including the day of discharge. Home health is covered for 60 days. (Medicare-certified) hospice is covered. Not covered: Physician services, long-term care, custodial services, and personal convenience
What is Medicare Part B? Discuss the financing and cost-sharing features of Medicare Part B. What main benefits are covered under Part B? What services are not covered?
Medicare Part B is supplementary medical insurance. It is financed through general tax revenues (75%) and by premium contributions based on income (25%). Benefits: physician services, ED services, outpatient surgery, diagnostic test and laboratory services, outpatient PT, OT, and SLP, outpatient mental health services, limited home health care under certain conditions, ambulance, renal dialysis, artificial limbs and braces, blood transfusion and blood components, organ transplants, medical equipment and supplies, rural health clinic services, annual physical exam ------------------------------------------------- The Shorthand of benefits... the main benefits of Medicare B is to cover necessary medical services and supplies needed for diagnosis or treatment of an individual's health condition. ------------------------------------------------------ Not covered: dental services, hearing aids, eyeglasses (except after cataract surgery), services not related to treatment or injury
immigration
Movement of individuals into a population
social contacts
Number and kinds of people with whom one associates; members of one's social network, number of activities a person engages in within a specified period of time
Who are midlevel providers? What are their roles in the delivery of health care?
Nurse Practitioners, Certified Nurse Midwives, clinical nurse specialist, certified registered nurse anesthetists, and Physician Assistants. The term midlevel providers (MLPs) refer to clinical professionals who practice in many of the areas similar to those in which physicians practice but who do not have an MD or a DO degree. Advanced practice nurses. (APNs) receive less advanced training than physicians but more training than RNs. They are also referred to as physician extenders because in the delivery of primary care, they can, in many instances, substitute for physicians. However, they do not engage in the entire range of primary care or deal with complex cases requiring the expertise of a physician."
What is adverse selection? What are its consequences?
Occurs when high-risk individuals-people who are likely to use more health care services than others due to poor health status-enroll in health insurance plans in greater numbers compared to healthy people. Premiums must be raised for everyone, making health insurance less affordable to healthy people.
host
One of the factors of the epidemiology triangle; an organism, generally a human , who receives the agent and become sick.
The Blum model points to four key determinants of health. Discuss their implications for health care delivery.
PG 62-64
Discuss the main cultural beliefs and values in American society that have influenced health care delivery and how they have shaped the health care delivery system.
PG 73-74 Some of the main beliefs and values prevalent in the American culture are outlined as follows:1. A strong belief in the advancement of science and the application of scientific methods to medicine.2. America has been a champion of capitalism. Due to a strong belief in capitalism, health care has largely been viewed as an economic good (or service), not as a public resource.3. A culture of capitalism promotes entrepreneurial spirit and self-determination. Hence, individual capabilities to obtain health services have largely determined the production and consumption of health care— which services will be produced, where and in what quantity, and who will have access to those services.4. Principles of free enterprise and a general distrust of big government have kept the delivery of health care largely in private hands. Hence, a separation also exists between public health functions and the private practice of medicine.
Summarize the government's role in technology diffusion.
PG. 192-196
Which "preparedness"-related measures have been taken to cope with potential natural and human-made disasters since the tragic events of 9/11? Assess their effectiveness.
PG. 60 Began in June 2002 - President Bush signed into law the Public Health Security and Bioterrorism Preparedness Response Act of 2002. Subsequently, the Homeland Security Act of 2002 created the Department of Homeland Security (DHS) and called for a major restructuring of the nation's resources with the primary mission of helping prevent, pro-tect against, and respond to any acts of terrorism in the United States.Now, health protection and preparedness involves a massive operation to deal with any natural or man-made threats.Includes appropriate tools and training for workers in medical care, public health, emergency care, and civil defense agencies at the federal, state, and local levels.Requires national initiatives to develop countermeasures, such as new vaccines, a robust public health infrastructure, and coordination among numerous agencies.It requires an infrastructure to handle / contain large numbers of casualties and isolation facilities for contagious patients.Hospitals, public health agencies, and civil defense must be linked together through information systems.The CDC has developed the National Biosurveillance Strategy for Human Health that most states and localities have strong biological laboratory capabilities and capacities,Strategies for expanding the surge capacity.
Distinguish between national health expenditures and personal health expenditures.
Page 255: National health expenditures are an aggregate of the amount the nation spends for all health services and supplies, public health services, health-related research, administrative costs and investment in structures and equipment during a calendar year.Personal health expenditures are a component of national health expenditures and comprise the total spending for services and goods related directly to patient care.
Health promotion and disease prevention may require both behavioral modification and therapeutic intervention. Discuss.
People may not have the knowledge necessary to improve their habits, or may need assistance to do so after they know they should. Behavioral modification could be quitting smoking, but therapeutic intervention can aid in this modification by offering programs to assist them in quitting.
What has been the main cause of the dichotomy between the way physical and mental health issues have traditionally been addressed by the health care system?
Physical functioning is reflected in behaviors and performance and can be more readily observed. Mental health is less objective because it often encompasses feelings that cannot be observed
Who are the major players in the U.S. health services system? What are the positive and negative effects of the often conflicting self-interests of these players?
Physicians, health service institution administrators, insurance companies, large employers and the government. Self-interests create competing forces within the system causing cost containment and achieving comprehensive system-wide reform to become nearly impossible.
phantom providers
Practitioners who generally function in an adjunct capacity. The patient does not receive direct services from them. They bill for their services separately, and the patients often wonder why they have been billed. Examples include anesthesiologists, radiologists, and pathologists.
Discuss how the concepts of premium, covered services, and cost sharing apply to health insurance.
Premium is the amount of an individual pays for an insurance policy. Covered services are services covered by health care plans. Cost sharing refers to deductibles, co-payments, and coinsurance.
demand-side rationing
Prices and ability to pay ration the quantity and type of health care services people consume
What are the major distinctions between primary care and specialty care?
Primary care focuses on the person as a whole, whereas specialty care cen-ers on particular diseases or organ systems of the body. Primary care is first-contact care and is regarded as the portal to the health care system. PCPs serve as gatekeepers. Primary care is longitudinal. In other words, primary care providers follow through the course of treatment and coordinate various activities, including initial diagnosis, treatment, referral, consultation, monitoring, and follow-up. Primary care providers serve as patient advisors and advocates. Primary care students spend a significant amount of time in ambulatory care settings, familiarizing themselves with a variety of patient conditions and problems. Students in medical subspecialties spend significant time in inpatient hospitals, where they are exposed to state-of-the-art medical technology."
What are the main objectives of public health?
Public health is concerned with ensuring conditions that promote optimum health for society as a whole. Its main objectives are to prevent disease, prolong life, and promote health through organized community effort.
planned rationing
Rationing that is generally carried out by a government to limit the availability of health care services, particularly expensive technology.
social resources
Refer to social contacts that can be relied upon for support, such as family, relatives, friends, neighbors, and members of a religious congregation. They are indicative of adequacy of social relationships.
morbidity
Refers to ill health in an individual and the levels of ill health in a population or group.
cases
Refers to individuals who acquire a certain disease or condition.
premium cost sharing
Refers to the common practice by employers that require their employees to pay a portion of the health insurance cost.
health risk appraisal
Refers to the evaluation of risk factors and their health consequences for individuals. Health risk appraisal is an important aspect of health promotion and disease prevention because it can be instrumental in developing avenues for motivating individuals to alter their behaviors to more healthful patterns.
balance bill
Refers to the leftover sum that a provider bills to the patient after insurance has only partially paid the charge that was initially billed.
What are the differences between the retrospective and prospective methods of reimbursement?
Retrospective methods of reimbursement involves evaluating costs of reimbursement by looking back at historical costs while prospective methods of reimbursement involves using certain criteria to predict (look forward) and evaluate reimbursement
Why is it that, despite the public and private health insurance programs, some U.S. citizens are without health care coverage?
Some don't qualify for the public programs because of their income, yet do not make enough to afford the private plans.
standards of participation
Standards established though health policy and regulation that state that providers must comply with standards established by the government to be certified to provide services to Medicaid, CHIP, and Medicare beneficiaries.
Discuss the relationship between technological innovation and health care expenditures.
Technological innovations have been the single most important factor in medical cost inflation. They have accounted for about one-half of the total rise in real (after eliminating the effects of general inflation) health care spending during the past several decades (CBO 2008; Sorenson et al. 2013). The impact of technology on costs differs across technologies, in that some—such as, cancer drugs and invasive medical devices—have significant cost implications, while others are cost-neutral or cost-saving (Sorenson et al. 2013). Three main cost drivers are associated with the adoption of medical technology. First, there is the cost of acquiring the new technology and equipment. Second, specially trained physicians and technicians are often needed to operate the equipment and to analyze the results, which often leads to increases in labor costs. Third, new technology may require special housing and set-ting requirements, resulting in facility costs (McGregor 1989)."
In general, discuss how technological, social and economic factors created the need for health insurance
Technology created new and better treatments for delivering medical care. The availability of new treatments was desirable and created demand. The costs (and need) for the treatments was unpredictable. In general, it increased the desire and, at the same time, made the care less affordable creating the opportunity for insurance to help spread the cost risk across a pool.
What is telemedicine? How do the synchronous and asynchronous forms of telemedicine differ in their applications?
Telemedicine, or distance medicine, employs the use of telecommunications technology for medical diagnosis and patient care when the provider and client are separated by distance. Similar to a virtual visit, it eliminates the requirement for face-to-face contact between the examining physician and the patient.Unlike virtual visits, however, telemedicine has applications in the delivery of specialized medical services. Examples include teleradiology, the transmission of radiographic images and scans; telepathology, the viewing of tissue specimens via video-microscopy; telesurgery, controlling robots from a distance to perform surgical procedures; and clinical consultation provided by a wide range of specialists. Synchronous technology allows telecommunication to occur in real time. Asynchronous technology employs store-and-forward technology that allows users to review the information later."
How does the Supreme Court ruling on the ACA affect Medicaid? How does the ACA affect the program?
The ACA had authorized the DHHS to withhold the federal share of financing as a penalty for states that refused to expand Medicaid. The US Supreme Court struck down this mandate. Consequently, states now had a choice to either expand or not expand their Medicaid programs without any penalty from the federal government. The ACA requires coverage for legal residents under the age of 65 with income up to 138% of the FPL. States can no longer use the assets test. Federal matching will be provided at 100% for newly eligible individuals for 3 years (2014-2016), with a gradual reduction each year to 90% in 2020. Beneficiaries who were already in the Medicaid program, coverage for preventive services is at the discretion of the state. States have the option to establish Health Homes (not to be confused with home health care) for Medicaid beneficiaries who have chronic conditions, including serious and persistent mental health conditions.
What provisions has the federal government made for providing health care to military personnel and to veterans of the U.S. armed forces?
The Tricare program was developed in response to the growing health care needs of military personnel, an increasing number of who are retirees. Congress requires Veteran Health Administration to provide services on a priority basis to veterans with service-connected illnesses and disabilities, low incomes, or special health care needs.
surge capacity
The ability of a healthcare facility or system to expand its operations to safely treat an abnormally large influx of patients.
universal access
The ability of all citizens to obtain health care when needed.
access
The ability of an individual to obtain health care services when needed.
Discuss the definitions of health presented in this chapter in terms of their implications for the health care delivery system.
The absence of illness or disease- this simply means you need no medical treatment. This implies that the only way to be healthy is to diagnose and treat disease with medical interventions, and doesn't account for prevention and health promotion. The state of optimal capacity of an individual to perform his or her social roles and tasks, such as work, school, and household chores. If unable to do these things they are considered sick, but many people still perform these tasks even while in pain, with a cold/cough, or mental distress. A state of physical and mental well-being that facilitates achievement of individuals and societal goals- This view recognizes the importance of harmony between the physiological and emotional dimensions. A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. (PG.47) recognizes the biopsychosocial model.
life expectancy
The average number of years an individual can be expected to live, given current social, economic, and medical conditions. Life expectancy at birth is the average number of years a newborn infant can expect to live.
fertility
The capacity of a population to reproduce
health plan
The contractual arrangement between the MCO and the enrollee, including the collective array of covered health services that the enrollee is entitled to.
health care reform
The expansion of health insurance to cover the uninsured.
What factors are associated with the development of health services professionals in the United States?
The expansion of the number and types of health services professionals closely follows population trends, advances in research and technology, disease and illness trends, and changes in health care financing and delivery of services. New and complex medical techniques, equipment, and advanced computer-based information systems are constantly introduced, and health services professionals must continually learn how to use these innovations. Specialization in medicine has contributed to the proliferation of different types of medical technicians. The changing patterns of dis-ease, from acute to chronic, and a greater emphasis on prevention create a greater need for professionals who are formally trained to address the consequences of behavioral risk factors and the delivery of primary care. Increased insurance coverage under the Affordable Care Act (ACA) will also increase the demand for health services professionals."
Discuss the government's role in the delivery and financing of health care, with specific reference to the dichotomy between public health and private medicine.
The federal government provides financing for MCR and MCD.• The federal government also sets standards for participating• Federal government delegates regulatory oversight to the state• Private hospitals and providers (physicians) deliver the care.• Scrutiny on quality of care is from the states through public health agencies for the delivery of individual care.• Reimbursement is for care, not health.
quad-function model
The four key functions necessary for health care delivery: financing, insurance, delivery, and payment
Discuss the main ways in which current delivery of health care has become corporatized
The main ways in which the current delivery of health care has become corporatized is by managed care, integrated health care services, advanced telecommunication, medical tourism, foreign dire investment in health services benefits foreign citizens, the creation of jobs overseas and medical care by the U.S. is in demand overseas. As a matter of survival, many physicians consolidated into large clinics, formed strategic partnerships with hospitals, or started their own specialty hospitals. There is a growing trend of phy-icians choosing to become employees of hospitals and other medical corporations. Corporatization has shifted marketplace power from individuals to corporations.
Discuss the relationship of dependency within the context of the medical profession's cultural and legitimized authority. What role did medical education reform play in galvanizing professional authority?
The medical profession's cultural authority is grounded in scientific knowledge, and its authority is legitimized when society accepts its competence in delivering specialized judgments. The profession's cultural authority is derived from the physician's superior knowledge and expertise in medicine. The patient becomes dependent on the medical profession's judgment and assistance. Advanced graduate medical education was instrumental in establishing the profession's cultural authority because it gave physicians a superior base of knowledge and skills. dependency is created by the profession's cultural authority because its medical judgments must be relied on to (1) legitimize a person's sickness; (2) exempt the individual from social role obligations, such as work or school; and (3) provide competent medical care so the person can get well and resume his or her social role obligations. Third, in conjunction with the physician's cultural authority, the need for hospital services for critical illness.
prevalence
The number or proportion of cases of a particular disease or condition present in a population at a given time.
incidence
The number or rate of new cases of a particular condition during a specific time.
To what extent do you think the objectives set forth in the Healthy People initiatives can achieve the vision of an integrated approach to health care delivery in the United States?
The overarching goals of the initiative, if achieved, should lead us closer to making that vision a reality. Especially creating environments that promote good health and promoting healthy development and healthy behaviors across all life stages. PG. 82
Briefly explain the prescription drug program under Medicare Part D. What provisions does the ACA have to reduce cost sharing?
The prescription drug program requires a payment of a monthly premium to Medicare, which is in addition to the premium to Part B. Certain beneficiaries that are low-income are automatically enrolled without having to pay a premium. The ACA states that all Part D drugs must be covered under a manufacturer discount agreement with the CMS. Beneficiaries are to receive discounts on drugs while in the coverage gap
Discuss the prospective payment system under DRGs.
The prospective payment system (PPS) under DRGs is used by Medicare to determine reimbursement rates for inpatient hospital care. The amount of payment is set per discharge rather than per diem. Hence, it is a rate established for bundled services. On admission, a patient is assigned a DRG category according to the principal diagnosis. Based on the patient's DRG classification, the hospital receives a set amount.
