Financing and structure of health care - 1&2
Physician Assistant 5081 with Parish at Eastern Virginia Medical School
About this deck
By: Kellie Gustas
Textbook:
Physician Assistants: Policy and Practice
Created: 2012-03-26
Size: 65 flashcards
Views: 70
Textbook:
Physician Assistants: Policy and PracticeCreated: 2012-03-26
Size: 65 flashcards
Views: 70
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Part of medicare that pays for inpatient, skilled nursing facility, home health and hospice
Part A: Hospital Insurance
how is part A funded
tax of earnings from employers and employees
Part of medicare that pays for physician visits, outpatient, home health care, and preventive services
Part B: supplementary medical insurance (SMI)
How is part B of medicare funded?
General revenues and beneficiary premiums
Part of medicare that is private plan enrollment (HMO, PPO, private fee-for-service) as an alternative to the traditional fee-for-service program
Part C; medicare advantage plan
T/F Part C of medicare is separately financed
False. Part C is not separately financed
Outpatient Prescription Drug Plan
Part D of medicare
How is part D financed?
pay monthly premium along with cost-sharing amounts for prescription: those with modest income may be eligible for assistance with premiums and cost-sharing amounts
T/F Most PDP (prescription drug plans) offer no gap coverage
True - 80% offer no gap coverage and the 20% that do only offer it on generic drugs
What is the coverage gap in Part D of medicare?
enrollees with at least $2,830 in total costs pay 100% of their drug costs until they have spent $4,550 out of pocket (then pay 5% of the drug cost or copayment for rest of year)
T/F many people who have medicare have supplemental insurance to help fill the gaps in medicares benefit package and help with cost-sharing requirements
True
What are the leading sources of supplemental coverage of medicare recipients
Employer and union-sponsored plans
dramatic expansion of the medicaid program that is integral to the coverage framework laid out in the new health care reform law, the ________
Affordable Care Act
supports the safety-net institutions that provide health care to low-income and underinsured
medicaid
How is medicaid financed?
Jointly by the federal government and the states (federal government matches state spending on medicaid)
T/F states participation in medicaid is voluntary
True - but all states participate
Medicaid is ____ financed but health delivery is in the ____ sector
publicly; private
____ is the most common health delivery system in medicaid
managed care
SCHIP
State children's health insurance plan
The primary federal agency for improving access to health care services for people who are uninsured, isolated or medically vulnerable
Health Resources and Services Administration
Health care program for more than 9.6 million uniformed service members and their families around the world
TRICARE
Payment based on each visit or each procedure provided
Fee-for-service
Resource-Based Relative-Value scale
Fees set for each service by estimating the time, mental effort and judgment, technical skill, physical effort and stress typically related to the service (medicare fee for service)
Contract on a discounted fee-for-service basis and require prior authorization for expensive procedures
PPO-manages care plans fee-for-service procedure
what was the previous form of reimbursement that allowed latitude in setting fees for service?
UCR - usual, customary, and reasonable
What was the UCR system replaced by?
Payer-determined fee schedules
The doctor sets each fee for each services
UCR
Medicaid determines how much they are going to reimburse the doctor and the doctor cannot bill the patient for the rest
Payer-determined fee schedules
What was put in place to attempt to correct the bias of physician payment that paid surgical and other procedures at a higher rate than primary care services
Resource-Based relative-value scale
the doctor contracts with Blue Cross to care for it patients at 70% of his normal fee - must contact Blue Cross in order to order an MRI for his patient
PPO discounted fee-for-service
One payment for all services delivered during one episode of illness
Payment per episode of illness - ex. surgery or delivery
One fee paid for one episode of illness no matter how many times the patient visited the healthcare provider or hospital
Diagnosis Related Groups
Patient gets cholycystecomy, doctor paid $1300, patient sees doctor 3 times after related to cholycystecomy - doctor still only paid $1300
Surgery - global fee
patient has pneumonia, doctor sees patient 5 times regarding the pneumonia, doctor is paid one fee for all services and procedures regarding the pneumonia
episode of illness - DRG
Who is at risk in traditional FFS programs?
whoever is paying bill - insurance co, government agency, patient
Who is at risk when bundling of services
health care provider
payments made monthly or yearly to a healthcare provider for each patient signed up to receive care
capitation - HMO pays fixed sum no matter how many services are provided
How can health care providers mitigate financial risk if they are part of an HMO and receive capitation
carve-outs: FFS payments for specified services
Risk adjusted capitation: higher monthly payments for elderly patients and those with chronic illness
Risk adjusted capitation: higher monthly payments for elderly patients and those with chronic illness
What are the advantages of capitation?
control costs, organization of care
Which tiered capitation structure encourages PCPs to limit the use of diagnostic and specialist services by returning to them any surplus funds that remained at the end of the year
Three-tiered structure: capitation-plus-bonus payment
How health care providers in the public sector and community clinics get paid
salary - combines payments for all services delivered during a month or year into one lump sum
two-tiered payment structure with HMO directly employing providers on a salaried basis
Staff model HMO
HMO contracts on a capitation basis with an intermediary provider group that pays individual providers a salary
group model HMO
how are most doctor's paid today?
fee-for-service (based on RBRVS or discounted PPO)
Do larger physician groups have more or less bargaining clout?
More bargaining clout
T/F there is a wide gap in salaries between PCP and specialists
True - leads to shortage of PCPs
What is shifts the financial risk on hospitals in hospital fee for service?
cost containment - by using per diem, DRG, capitation payments
payment of bundling in a lump sum all the services provided for one patient for each day the patient is in the hospital
per diem payment to hospitals
utilization review
(per diem payment) nurse reviews charts of hospital patients for insurer - if nurse decided the patient is not acutely ill, the HMO may stop paying for additional days
fixed payment is made for all hospital services for 1 year
global budget (payment method for hospital per institution)
bundling of services and/or capitation places economic pressure on healthcare providers and hospitals to ____ the number and cost of services offered
Limit
the flow of money (premiums/taxes) from individuals and employers to the health insurance plan (private or government programs)
financing
the flow of money from health insurance plans to healthcare providers, hospitals, and other providers
reimbursement (payment)
T/F cost control mechanisms can only be applied to the financing component of health care
False- cost control mechanisms may be applied to both the financing and reimbursement components of health care spending
tax financed health insurance - to increase health care expenditures required increase in taxes; government regulation of taxes serves as a control over public expenditures for health care
Regulatory financing strategy: example Medicare Part A
Health insurance plans compete on the basis of price with lower cost plans being rewarded with having a greater number of enrollees; make employers, employees, and individuals more cost-conscious in their health insurance purchasing decisions
competitive financing strategy
Employees are more/less cost aware when employers limit the amount of the insurance premium that they will pay
More
Quantity of services often ___ when prices are strictly controlled
increases
T/F Medicaid FFS rates are much lower than private insurance rates and make it difficult for these patients find providers
true
T/F price controls affect quality of care and patient satisfaction
true - physicians see high volumes of patients seen for brief visits
1. changing the unit of payment
2. patient cost sharing
3. utilization management
4. supply limits
2. patient cost sharing
3. utilization management
4. supply limits
Methods to control the use of services
controls on the number of healthcare providers and other caregivers and material resources
supply limits
What are the two types of financing controls
1. regulatory - taxes
2. competitive
2. competitive
What are the two types of reimbursement controls
1. price controls
2. utilization controls
2. utilization controls
the most successful strategies for cost control are those that emphasize _____ cost containment and less cost containment at the _____ level
Global; individual
About this deck
By: Kellie Gustas
Textbook: Physician Assistants: Policy and Practice
Created: 2012-03-26
Size: 65 flashcards
Views: 70
Textbook:
Physician Assistants: Policy and PracticeCreated: 2012-03-26
Size: 65 flashcards
Views: 70
About StudyBlue
STUDYBLUE makes things that make you better at school.
Things like online flashcards with photos and audio.
Things like personalized quizzes and friendly reminders about when (and what) to study next.
Think of it as a digital backpack™: access to all of your study materials online and on your phone.
STUDYBLUE exists to make studying efficient and effective for every student, for free. Join us.
“I have used this website for three exams, and I see a huge difference in my test results.”
Naj
Naj