6600 Module Questions - kajd PDF

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6600 Guided Learning Questions

MODULE 1 Textbook 1. When did insurance first emerge in the American marketplace? - During the civil war àcovered personal injury related to travel by rail or steamboat - Paved the way for more inclusive plans that covered illnesses and injury; precursor to disability plans 2. What is an HMO? - Health Maintenance Organization - Another way to organize and finance HC delivery - Allows employers to prepay for HC for few cents a day (1st was Henry Kaiser who owned shipyards and factories) 3. Describe the differences between an indemnity plan, an HMO, a PPO, a POS, a CDHP, an HDPD, an HAS, an HRA, and an FSA. - Indemnity plan o Make a fixed cash payment towards a particular medical expense based on what services are covered and what reimbursement method is used by the insurance company o Insured person decides when and from whom to seek HC services àif covered, provider submits claim after provided o The individual carries the risk of covering the cost of his/her care o Fee-for-service plans require premium, deductible, and coinsurance payments. - HMO: (health maintenance organization) o HC service delivery and financing integrated under managed care o Original HMO, individuals joined group practices where insurance premiums

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provided budget to cover cost; physicians salaried so costs were known o Managed HC system in which providers offer health care to members for fixed periodic payments PPO (preferred provider organization) o Combines indemnity and managed care o Enters contract with providers and creates provider network o If patient uses preferred provider, cost of services discounted; out-of-network provider, only portion covered o Out of pocket deductible o The most popular; which contracts with physicians, hospitals, clinics, and pharmacies to provide a network of care providers for its beneficiaries. POS: (point of service) o Hybrid of PPO and HMO o Enrollees decide which provider they will see without prior authorization from primary care provider o Managed care plan that permits patients to receive medical services from nonnetwork providers CDHP: (consumer-driven health plan) o Combination of high deductibles and pretax payments o Patient care driven by physicians and patients do not have adequate info to discern

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between cost and quality o 1. Overuse of services bc individual do not know the cost of services and don’t carry substantial financial risk in terms of being responsible for paying for services 2. HC consumers become better educated about services and costs o Medical insurance that combines a high-deductible health plan with one or more tax preferred savings accounts that the patient directs HDPD: (high deductible health plan) o Lower premium and higher deductible that must be paid before receiving coverage o Provide catastrophic coverage and guard against major medical costs HAS: (health savings plan) o Created so people with HDPDs could receive tax-preferred treatment for money saved for medical expenses o Is an account holder’s individual account that can be used to pay for qualified med/pharm expenses? o Can be funded by employer or employee with pretax dollars up to limit (varies yearly) o Includes deductible, but can use HAS to pay for out-of-pocket expenses before they meet the deductible o Funds deposited but not withdrawn carry over the next year o consumer-driven health plan funding option under which funds are set aside to pay for certain healthcare costs HRA: (health reimbursement account) o Funded only by an employer àno pretax dollars from the employee can be added o Money in account only used for medical expenses o Unused funds roll over o consumer-driven health plan funding option where an employer sets aside an annual amount for healthcare costs FSA: (flexible spending account) o Allows employees to have their own employers set aside pretax dollars from wages to pay for out-of-pocket medical expenses o Can include co-payments, deductibles, qualified prescription drugs, medical devices o No carry-over of unused funds (use it or lose it)

4. What is ERISA? What is HIPAA? - ERISA o Federal law that sets minimum standards for employer-sponsored benefits o Requires hc plans to provide participants with information regarding plan features, participants rights to establish grievance through an appeal process and disclosure of the plans’ activities o law providing incentives and protection for companies with employee health and pension plans - HIPPA o Amendment to ERISA that provides protection for working Americans and their families who have preexisting medical conditions o Addresses patient privacy of identifiable medical information and electronic transmission of hc information 5. What is the ACA? Describe the impact of the ACA. - Affordable Care Act àto expand insurance coverage to ~ 32 mill uninsured Americans & strengthen existing coverage

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Signed by Obama which requires all Americans to have health insurance or they’ll face penalties o Can purchase from state or federal exchanges

o Those who can’t afford àcan apply for subsidy o Also available through employers (cover only full-time employers) - Some of changes don’t apply to plans that existed before 3/23/10 o Aka grandfathered plans o Those covered under these plans don’t have same level of protection o Changes the way private insurers conduct business o Provides new opportunities for nurses to demonstrate quality outcomes o Unknown if impacted cost of healthcare insurance 6. Describe the historical trajectory of Medicare. How does its role differ now from where it began? - 4 parts: A (cover hospital bills), B (physician services), C (hospital/physician services/ and prescription benefit), D (prescription drug plan) - President Lyndon B. Johnson signed amendments to the Social Security Act on July 30, 1965. - part of Johnson's social reform movement ("Great Society,") which set goals to eliminate poverty and racial injustice. - From protector: lifted millions of seniors out of poverty and provided financial protection to seniors and their children àinnovator of payment reform under ACA (the largest HC payer at the center of the delivery system) 7. Who is eligible for Medicare? - People 65+ and those with disabilities; added people with ALS in 2001 - Must work for 40 quarters (10 years) 8. Which model of healthcare does the US use? - Only nation to define access to healthcare based on social classifications 9. What is Medicaid? - Medicaid is health insurance available to certain people and families who have limited income and resources (younger than 65) - Pays for physically disabled, developmentally disabled adult, mentally ill, AIDS, substance abuse, elderly persons, etc. 10. What is cost-sharing? How is it used in US healthcare? - refers to the fact that you and your health insurer both pay a portion of your medical costs during the year - deductibles, copayments, coinsurance 11. Describe healthcare financing in the US. How does it differ from other developed nations? - Based off social classifications à private insurance for many productive members of society - Big gaps in insurance that leave out lots of people uninsured o unemployed people without small children o families who make slightly more than the cutoff for Medicaid but can’t afford private insurance o working people whose employers don’t provide healthcare insurance - 41% Pay out of pocket - Fewer see doctors when need - $606 spent per person 12. How many Americans defer care due to cost? 32% Commonwealth Fund International Profiles of Healthcare Systems

Link:https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publicatio ns_fund_report_2016_jan_1857_mossialos_intl_profiles_2015_v7.pdf 13. Compare healthcare in the US to other countries around the world. What are the major differences you see? Are these advantages or disadvantages? 14. Reviewing table 2, what is similar about the US and its 17 health indicators when compared with other countries? What’s different? 15. What are the “safety nets” in American healthcare? - A variable and patchwork mix of organizations and programs deliver care for uninsured, low- income, and vulnerable patients in the United States, including public hospitals, local health departments, free clinics, Medicaid, and CHIP 16. What agencies provide oversight to the US healthcare system? 17. What are the major strategies to ensure quality care in the US? - Released the National Quality Strategy, lays out national aims and priorities to guide local, state, and national quality improvement efforts; Current initiatives include efforts to reduce hospital-acquired infections and preventable readmissions - CMS has moved toward increased public reporting of provider performance data in an effort to promote improvement. One such initiative is Hospital Compare, a service that reports on measures of care processes, care outcomes, and patient experience at more than 4,000 hospitals. - CMS is making Medicare data available to “qualified entities,” such as health improvement organizations, which are beginning to release data on payments made by Medicare to individual physicians and amounts paid to physicians and hospitals by pharmaceutical and device companies; intended to both increase transparency and improve quality. - States have additional public reporting systems and measures, including some that address ambulatory care. Consumer-led groups, such as Consumers Union and the Leapfrog Group, also report on quality and safety. - Incentives to reduce avoidable hospital readmissions among Medicare patients by way of financial penalties. & to reduce hospital- acquired conditions, by reducing Medicare payments to the lowest-performing hospitals - implementing a variety of pay-for-value programs. Medicare payments are redistributed to the highest performers on a composite of cost and quality measures. 18. What are health disparities? What is being done to address them? - preventable differences in the burden of disease, injury, violence, or opportunities to 1 achieve optimal health that are experienced by socially disadvantaged populations. Populations can be defined by factors such as race or ethnicity, gender, education or income, disability, geographic location (e.g., rural or urban), or sexual orientation. - Federally qualified health centers (FQHCs), which are eligible for certain types of public reimbursement, provide comprehensive primary and preventive care regardless of their patients’ ability to pay. FQHCs largely provide safety-net services to the uninsured. - Medicaid and CHIP provide public health insurance coverage for certain low-income populations. - ACA contains a number of provisions aimed at reducing disparities: subsidies to enable low-income Americans to purchase insurance through the exchanges; efforts to achieve parity for mental health care and substance abuse services; and funding to community health centers located in underserved communities. - public and private initiatives at the local and state levels. 19. Describe “meaningful use” in relationship to the electronic health record.

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Financial incentives for hospitals and physicians to adopt Electronic health record systems designed to gradually raise the threshold for EHR functionality above which providers receive incentives and avoid penalties. The current focus is on information exchange. Khan Academy Healthcare System Overview 20. Describe the payor structure in the American healthcare system. - Anyone who’s paying for service - Aka Health plans (can be private or government companies) like Medicare - insurance companies (paid for by either employers or patients) àpay providers (doctors) àpatient (care) - Population also pay taxes to government (Medicare); care paid for by govt 21. What is a copay? What is the function of copays? - Small payment ($10) paid by the patient in addition to what’s paid by insurer - So patients won’t pay for thing they don’t really need 22. What is the difference between an HMO and a PPO? - HMO: combination of insurance company and provider o Company that acts as an insurer (we pay a premium) àbuy coverage àcover care to try to integrate with provider o Set list of doctors (pre-negotiated); if you don’t use those (don’t get paid for) -

PPO: o Still get list àmore flexible (plan still pays for some amount if you choose someone out of list); less managed Kaiser Family Foundation Health of the Healthcare System 1. What are the four attributes that we can measure to assess the health of our healthcare system? - Health, Quality, Cost, Access 1. Of countries comparable to the US, which country has the highest rate of deaths preventable by healthcare? - United Kingdom àGermany àAustria/Netherlands àSweden àJapan àAustria àFrance 1. How does healthcare spending compare in the US to other countries? - 17 cents goes to healthcare for every $1, compared to others who spend a dime 1. What are our major health expenditures in the US? - We pay more money for heart surgeries, childbirth, MRI, lot of prescription drugs 1. How many go without care when they need it due to cost? - 1/10 , 9% 1. What impact did the Affordable Care Act have on health insurance coverage? - Lower rates of death for cancer, more likely to survive more than 5 years when diagnosed with those cancer - Total spending lower The Economics of Healthcare: Crash Course Econ #29 1. How is healthcare different from other kinds of market resources? - Never know when you’ll need it - Don’t wait for credit card before they treat you 1. Compare and contrast public healthcare systems and private healthcare systems. How does the system in the US differ from that of the UK, Canada, and France? What are the advantages and disadvantages of each system? - Canada: government pays for health care through tax; doctor’s offices are private offices they get paid by the government; Hospitals/operating tables = public property; hospital

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staff = public employees (like school teachers) France:healthcare providers paid by non-profit insurance funds; all citizens have to have insurance àcan choose doctor o Most French providers including hospitals are private businesses UK: socialized healthcare system àfunded by govt by taxes àdoctors paid by govt US: little of both o Hospitals private firms o Household covers by private insurers

o Also have single payer system for those over 65, and below poverty line 1. What is a single-payer system? - Government is doing most of the paying (Canada) - Have to pay for prescription drugs, eye glasses, dental care 1. What are the tax-payer funded insurances in US? - 1/3 Medicaid, Medicare, VA, Healthcare for active military 1. How do those who are uninsured differ from those who are insured? - Uninsured: tend to be younger, racially diverse, part-time/low wage job, employers don’t offer insurance o Unpaid medical expenses 1. What are factors that increase American Healthcare costs? - US spending 2x as more on one person - High quantity of care (patients want more tests than necessary), Prices expensive for same machines, Blizzard of paperwork (administrative cost) 35. What does it mean to have a pluralistic healthcare system? How would you describe the US healthcare system? - Private sector is main part of the system - also has public sector, private for profit sector, and private not for profit sector(United States, India, Nigeria) 1. What is the Iron Triangle? - Mutually beneficial relationship between members of congress (want to be re-elected) and bureaucracy (want to protect funding/ jobs) and lobbyist (advance interest of client) 1. How does the Iron Triangle affect healthcare? Work towards policies that don’t necessarily work toward the benefit of the people 1. What did the Affordable Care Act do? - Obama care (controversial): law - Obtain Insurance of pay a fee - Access improved and electronic record keeping Healthcare Triage: Access to Insurance Doesn’t Guarantee Access to Care 39. Explain what is meant by the idea that access health insurance does not mean access to health care. - When asked if patients could get a same-day or next-day appointment with their provider, 43% said no - When asked if somewhat easy to get care after regular working hours, no. More likely to use emergency room care - When new patients given health insurance, more patients access the health care system while there’s still not enough practitioners, making it even harder to access health care 40. Does the ACA improve access to healthcare? Explain your thoughts. - Access was a problem before, and still a problem now

41. What are the major challenges facing the US healthcare system? - US has fewer general practitioners per population than other countries (Supply/Demand) - Expense of obtaining care; Review links at the bottom of the module: 1. What is public health? - Looks at health of community; research risk and act to prevent before they occur - Improve housing, sanitation - Encourages healthy behaviors - Works to track disease outbreaks, prevent injuries, and shed light on why some of us are more likely to suffer from poor health than others 1. What is health equity? What are barriers to health equity? - means everyone has a fair and just opportunity to be healthier. - Barriers: policies and practices 1. Fill out table below Four Basic Models of Healthcare systems

Key features

Beverdige Model

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Disadvantages

Named after William Beveridge, the daring social reformer who designed Britain's National Health Service. health care is provided and financed by the government through tax payments, just like the police force or the public library. Many, but not all, hospitals and clinics are owned by the government; some doctors are government employees, but there are also private doctors who collect their fees from the government. In Britain, you never get a doctor bill. low costs per capita, because the government, as the sole payer, controls what doctors can do and what they can charge Great Britain, Spain, most of Scandinavia and New Zealand. Hong Kong still has its own Beveridge-style health care, because the populace simply refused to give it up when the Chinese took over that former British colony in 1997. Cuba represents the extreme application of the Beveridge approach; it is probably the world's purest example of total government control

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Bismarck Model

- Named for the Prussian Chancellor Otto von Bismarck, who invented the welfare state as part of the unification of Germany in the 19th century. fairly familiar to Americans. It uses an insurance system -- the insurers are called "sickness funds" -- usually financed jointly by employers and employees through payroll deduction. have to cover everybody, and they don't make a profit. Doctors and hospitals tend to be private in Bismarck countries; Japan has more private hospitals than the U.S. Although this is a multi-payer model Germany has about 240 different funds -- tight regulation gives government much of the cost-control clout that the single-payer Beveridge Model provides. Germany, of course, and France, Belgium, the Netherlands, Japan, Switzerland, and, to a degree, in Latin America

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Advantages

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both Beveridge and Bismarck.

Health Insurance Model

uses private-sector providers, but payment comes from a government-run insurance program that every citizen pays into. no need for marketing, no financial motive to deny claims and no profit, these universal insurance programs tend to be cheaper and much simpler administratively The single payer tends to have considerable market power to negotiate for lower prices; Canada's system, for example, has negotiated such low prices from pharmaceutical companies that Americans have spurned their own drug stores to buy pills north of the border. National Health Insurance plans also control costs by limiting the medical services they will pay for, or by making patients wait to be treated. The classic NHI system...