Ch 6 Health Care Systems

What is the central role of health services financing in the US
Fund health insurance
What is the primary mechanism that enables people to obtain health services
health insurance
the phenomenon called moral hazard results directly from
health insurance coverage
liberal reimbursement for a given technology will ____ innovation/diffusion of that technology
increase
controlling total health care expenditures by restricting financing for health insurance
Demand side rationing
in national health care systems total expenditures are controlled mainly by
supply side rationing
national health expenditures E =
E = P x Q
in general sense what is primary purpose of insurance
protection against risk
private health insurance is also called
voluntary insurance
under community rating
both high and low risk people are charged the same premium
which method of risk assessment is required by ACA for individual and small group health insurance
adjusted community rating
under experience rating
favorable risk groups pay a lower premium than high risk
what is the main advantage of group insurance
risk is spread out among a large number of insured
self insurance was spurred by
government policy
the employee retirement income security act
exempts self insured plans from certain mandatory benefits
cost is shifted from people in poor health to the healthy when
premiums are based on community rating
health insurance pays for medical care after insured pays first 1000
deductible
copayment is generally paied
each time the insured revives health care services
what was the main conclusion of the rand health insurance experiment
cost sharing lowered health care utilization without any significant health consequences
medical policies are sold by
private insurance companies
the ACA specifies that ____ can be covered under parents insurance plans
children under 26
how are preexisting medical conditions covered under the ACA
private insurance plans have to cover them starting 2014
under ACA what purpose do the exchanges serve
they allow individuals and small businesses to purchase health plans
in general how do bronze, silver and gold health plans differ
they differ according to cost sharing
what criterion does ACA use to classify an employer as a large employer
50 or more full time employees
to purchase private insurance through an exchange premium subsidies are made available to people with incomes up to
400% federal poverty line
majority of beneficiaries reviving health care through medicare are
elderly
main function of Medicare payment advisory commission MedPAC
advise the US congress on carious issues affecting the medicare program
to finance medicare part A
all income earned by a working person is subject to medicare tax
skilled nursing care is covered under _____ of medicare
part A
the HI portion of medicare is financed through
payroll taxes
for medicare beneficiaries the max stay in an SNF during a benefit period cannot exceed
100 days
for hospitalizations medicare beneficiaries must pay a deductible
once per benefit period
Medicare part B premiums are
income-based
SMI provides
physicians services
Part C of medicare specifially covers
–> NONE OF THE FOLLOWING
rehab services; preventative care; prescription drugs
why was medicare part C created
to channel beneficiaries into managed care programs
the donut hole in medicare prescription drug coverage
provides no benefits until the beneficiary qualifies for the catastrophic level
the SMI trust fund is for
parts B an D
the primary criterion to become eligible for medicaid
financial status
by law federal matching funds to the states for medicaid cannot be less than
50%
the insurance arm of military health care is called
tricare
to receive payment for services delivered providers must file a ___ with third party payers
claim
the use of fee for service reimbursement
has been greatly reduced
_____ reimbursement is based on the assumption that health care is provided in a set of identifiable and individually distinct units of service
fee for servce
what is the incentive under fee for service reimbursement
providers have an incentive to deliver nonessential services
in general prospective payment systems establish reimbursement for
bundled services
RVU’s reflect
resource inputs
preferred providers are paid
negotiated discounted fees
when a fixed monthly fee per enrollee is paid to a provider its called
capitation
capitation removes the incentive to
provide unnecessary services
under retrospective reimbursement a health care organization is paid according to
the costs incurred in operating the institution
wheat perverse incentive is present in retrospective reimbursement
providers can increase their profits by increasing costs
the amount of reimbursement is determined before the services are delivered
prospective reimbursement
what is not a type of prospective reimbursement methodology
cost-plus
a DRG represents
a group of principal diagnoses
an MS-DRG method of reimbursement an acute care hospital is paied
a fixed amount for a particular DRG classification
under the DRG method of reimbursement a psychiatric hospital is paid
a per diem rate based on psychiatric DRG’s
how is case mix determined for an inpatient facility
a comprehensive assessment of each patient is done
what is the minimum data set (MDS)
a patient assessment instrument for skilled nursing facilities
if national health expenditures amount to 18% of the GDP
health care consumes 18% of the total economic production
the largest share of national health expenditures is attributed to
personal health care
public/government share of the total health care spending in the US is approximately
45%
adverse selection makes health insurance less affordable for
those in good health
Medicaid recipients are classified as medically uninsured t/f
FALSE
Health insurance increases the demand for heath care services t/f
true
tax policy in the us provides an incentive to obtain employer based health insurance t/f
true
people in older age groups represent a higher risk than those in lower age groups t/f
true
under community rating people are charged in the same regardless of health risk t/f
true
today the majority of health insurance exists in the form of managed care plans t/f
true
by law a health insurance plan must cover work related injuries t/f
false
the government plays a significant role in financing health care services in the united states t/f
true
it is illegal for an insurance company to sell a medical plan to someone who is covered by medicaid t/f
true
under the ACA private health insurance will no longer be the main source of coverage t/f
false
the ACA requires that employers provide health insurance to part time workers if the employer has 50+ woerks
false
health insurance plans are prohibited from having lifetime dollar limits on medical benefits t/f
true
health insurance plans are allowed to have annual dollar limits on a persons medical benefit t/f
false
undr medicare program, eligibility criteria and benefits are consistent throughout the US t/f
true
part D of medicare does not require the payment of a premium t/f
false
long term care services for the elderly are covered under medicare
false
under the medicaid program eligibility criteria and benefits are consistent throughout the us t/f
false
state governments are required to partially finance the medicaid program t/f
true
according to a US supreme court decision individual states can decide whether or not to expand their medicaid programs to comply with ACA
true
research shows that prospectively set bundled payment methods are effective in reducing health care t/f
true
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