Term
| What is the world without insurance? |
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Definition
a. Physicians and hospitals can charge whatever they want to patients.
b. Patients say they will pay anything to get their health back, and often lack other options for obtaining health care, due to deficiency of local options or urgency of time.
c. Patients sometimes incur excessive unforeseen medical expenses.
d. Patients often are unable to compensate healthcare providers for the services rendered.
e. Healthcare providers are less willing to take risks on establishing new healthcare institutions. |
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Term
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Definition
| The amount the insured person has to pay the insurance company (usually paid monthly). |
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Term
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Definition
| The amount the insured person pays at the time of service (e.g., $30 for a clinic visit or $15 for a particular drug |
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Term
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Definition
| The amount an insured person must pay “out-of-pocket” before the health insurance begins to pay. |
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Term
| What problems came about when health insurance was introduced? |
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Definition
- In short, everyone tries to get the biggest slice of the financial pie now in the hands of the health insurance companies.
- Health insurance companies leverage their volume of subscribers to drive down the reimbursement to medical care providers. Providers still provide care because they agreed to do so.
- Health care providers and hospitals counter by increasing the cost of medical care. Insurers pay because they agreed to do so.
- Patients demand more and more care in order to “get what they have already paid for.”
- Insurance companies ended up receiving too little funds from patients to pay the rising costs of healthcare. |
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Term
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Definition
| A condition that a patient is known to have that is not covered by health insurance. |
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Term
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Definition
| The maximum amount that an insurance company agrees to pay, as specified in the plan that is purchased. |
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Term
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Definition
| The group of healthcare providers that has agreed to a reduced payment in order to have access to a larger number of patients. |
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Term
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Definition
| High deductible plan that covers the patient in the event of excessive medical expenses. |
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Term
| Health Maintenance Organization (HMO) |
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Definition
- PCP is the gatekeeper to more specialized care.
- In order for medical expenses to be covered, the provider has to be “in-network”. |
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Term
| Preferred Provider Organization (PPO) |
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Definition
- There is no gatekeeper to the specialist.
- Patient can see whomever they want; however, the cost is higher for “out-of-network” medical care. |
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Term
| What problems came about when HMOs and PPOs were introduced? |
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Definition
- The HMO and PPO drive down the payments to physicians and hospitals.
- As physicians receive less compensation, the quality of visit is decreased in order to generate quantity of visits.
- The patient pays more and more for less and less medical care.
- In short, the third party payers drove down the cost of care. The physicians counter by decreasing the quality of care. The patient loses.
- Physicians that are unsatisfied with the new arrangement exit the system and establish new systems. |
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Term
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Definition
- Heavily utilized by patients w/o any third-party coverage
- Usually offers no primary or secondary prevention |
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Term
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Definition
- Physician refuses to take any third-party payment, essentially returning back to the old patient-physician system
- Patient may or may not carry additional “major-medical only” coverage |
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Term
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Definition
| A patient pays a nominal fee based on income. This is usually run by a charity with a volunteer physician in order to minimize costs. |
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Term
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Definition
| Physician charges an annual fee (e.g. $1200/yr) for a specifically designated set of services (e.g. unlimited visits, or 4 visits a year) |
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Term
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Definition
| Physician offers unique services not covered by insurance but desired by affluent patients (usually cosmetic in nature) in order to increase clinic revenue (e.g. Botox injections) |
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Term
Group physician networks
- Clinic systems
- Physician hospitals
- Day-surgery centers |
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Definition
| In an effort to exclude third-party systems and regain control of their own payments, physician groups join clinics together, build their own hospitals, and run their own surgery centers. |
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Term
| Which usually offers patients a greater variety of physicians to choose from: HMO or PPO? |
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Definition
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Term
| Why might a 63-year-old patient with newly diagnosed multiple myeloma have a difficult time obtaining insurance? What hope might this patient have of medical care in the future? |
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Definition
- Pre-existing condition, until 2014, when that no longer can be exclusionary
- Also, when turn 65, can go on Medicare, which doesn’t exclude anyone |
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Term
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Definition
| The medications for which insurance companies will pay. Generics are preferred. |
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Term
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Definition
| Evaluation of the appropriateness, necessity, and efficiency of health care services. |
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Term
| Resource-based Relative Value Scale |
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Definition
| A scale that determines what a physician should be paid for a procedure (CPT code) or service in a specific region of the country, based on physician work, regional practice expense, and regional malpractice expense. |
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Term
| Health Plan – Managed Care Organizations (MCO ) – Health Care Organizations |
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Definition
- Organization that attempts to maximize quality of care and minimize the cost of care.
- Uses techniques such as encouraging patients and physicians to choose less costly care, controlling inpatient admissions and lengths of stay, and emphasizing preventive medicine.
- Accomplished through a designated utilization management person or department. |
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Term
| What about those without the financial resources for healthcare? |
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Definition
- Medicare
- Medicaid
- Children’s Health Insurance Plan (CHIP)
- City-, county-, or state-funded health networks
- Federally-funded teaching hospitals
- Federally-funded VA hospitals
- Universal health care |
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Term
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Definition
Payment is provided for a specified service
- Surgical procedure
- Clinic visit
- Inpatient visit |
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Term
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Definition
Fixed payment for a period of time or number of patients
- ER shift/minor emergency shift
- Concierge practice
- HMO |
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Term
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Definition
Specified amount, regardless of work performed
- Universities
- Hospital administration
- Base salary |
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Term
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Definition
Payment is increased if a physician meets pre-established targets.
Increased pay by the health care organization for meeting certain criteria such as preventive medicine targets (vaccines, colonoscopy, HgbA1c) |
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Term
| Nonpayment for performance |
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Definition
No payment is made for a complication that could have been avoided.
A funding entity may agree NOT to pay a physician for complications such as leaving a catheter in place, nosocomial infections, and surgical site infections |
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Term
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Definition
- “Young Invincibles”: These are people (usually under 30) that tend to not have many health problems and tend not to purchase insurance. In order for a third-party payer to afford to care for an ailing patient at a low premium cost to that patient, healthy patients must be present in the system to bear the burden of the additional expense.
- Excessive preexisting conditions: There are some patients that are unable to get any health insurance at a reasonable cost because of their preexisting conditions. The provider does not want to take on the high risk of providing care for the patient.
- Freedom of choice: Patients that need others to carry the burden of their healthcare expenses are at odds with those that want to be free to not have to carry that burden. The US government would like everyone to carry the burden via the “Individual Mandate” in the PPACA. Others argue that this violates their freedom.
- Excessive complexity: All this complexity leaves patients at a loss to understand where they need to go for healthcare. Additionally, this complexity requires hiring individuals to manage the complexity which drives up the cost of healthcare.
- Everyone still wants the biggest possible piece of the pie: Patients want the highest-costing care. Physicians want the highest reimbursements. Insurance providers want the largest profits. Drug companies want the largest possible profits.
- Physician shortage: Many physicians now see better opportunities elsewhere and are leaving full-time medicine. Older physicians are tired of the complexity and will leave practice if reimbursements decrease. The population continues to increase and the percentage of geriatrics in the population is also increasing.
- Insufficient government funds: It will be very difficult for the government to pay for Medicaid and for Medicare for the baby boom generation. |
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Term
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Definition
- Government intervention to regulate the system.
- Patients taking responsibility for their own health via the internet, OTC medication options, and complementary and alternative medicine.
- Patients seeking US-trained physicians practicing in developing countries where the cost of care is low.
- New generic medications that help lower the cost of health care.
- Cooperative healthcare teams that help reduce the need for costly hospitalization.
- More mid-level practitioners to meet the rising demand
- A four-level healthcare system |
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Term
| What is the difference between being paid by capitation and fee-for-service? |
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Definition
Fee-for service: payment provided for specific service
Capitation: fixed payment for a number of times or number of patients |
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Term
| What must a hospital submit to a third-party payer in order to receive payment for services? |
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Definition
ICD-9 - diagnosis codes
CPT codes - procedures performed |
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Term
| What department in a hospital oversees the maximization of the quality of care while minimizing the cost of care? |
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Definition
| Utilization Management Dept. |
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