Hsm 541 Study Guide Midterm

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includes an amount to cover the administrative

load, which encompasses the cost of insuring, including risk assessment, marketing, and

claims processing

US has no national health insurance or universal coverage. In the past several decades,

the concept of health insurance has expanded to embrace most interactions with the

health services system, including physicians’ services, and mental health, dental, and

vision services. Health insurance has therefore become more of a financial function for

costs than a risk transference function for unexpected costs

PPO: preffered provider organizations POS: point of service, HMO (health maintanc

organization) HIPAA health insurance portability and accountability

No insurance for Redlining, the second method of direct risk adjustment, denies insurance coverage to certain individuals or groups because of the hazardous nature of their employment, presumed high-risk lifestyles, a history of excessive claims, a propensity toward litigation, or other potential risks. Or co-pay indirect risk

Health insurance should 1)predict health services costs with accuracy;

2. treat participating HMOs reasonably and fairly;

3. be difficult for participating health plans to manipulate;

4. respect patient privacy and confidentiality;

5. create incentives for appropriate care; and

6. be feasible and inexpensive to administer.

Self Funded and Public Health Insurance

Public health insurance programs fill in some of the gaps left by private insurance

In self-funded—sometimes called self-insured—programs, the employer assumes the responsibility of defining a benefit package and paying directly for covered services, thus reducing or eliminating the need for an insurance company.

Chapter 7- Financing of Health Services

How Health Services are Financed

Insurers are third parties… private insurance pays for majority of health services

Cost is the amount spent to produce a good or service.

Cost containment strategies are regulatory interventions employers or payers, to control health services costs; the term to mean the containment or control of expenditures.

Expenditures are the amounts spent for health services goods or services.

Price is the amount charged for a health services good or service.

Major health expenditures :personal health services, including hospitals, physician services, drugs, nursing home care, and other personal services, and program administration

Price increase: by general inflation;

• medical price inflation;

• technology and the increased intensity of services provided per capita;

• population growth;

• the availability of health insurance and the resulting loss of individual accountability;

• the increased number of elderly, who require more health services;

• growth in national and personal incomes, which permits people to spend more on health services; • the increased complexity of administering a multipayer system;

• fraud and abuse;

• defensive medicine (which may include potenially ineffective care);

• malpractice;

• the growth of government health programs, such as the CHIP;

• the system’s emphasis on curative rather than preventive health services;

• fee-for-service payment systems; and

• market failure

The “protective” role of health insurance, whereby the insured are insulated from the true costs of their care, is a major factor in increasing health services expenditures: demographics , technology, GDP, expansion plan

The focus in the U.S. health services system on curative and therapeutic interventions, rather than on health promotion and disease prevention, is another cause of increasing health services expenditures

Provider Payment Mechanisms: s,

fee-forservice, primary :If the patient had health insurance, the insurer paid this charge or some portion thereof as specified in the insurance policy. Charges varied by geographic area, specialty of provider, and other variables

flat fee per medical case, flat fee per patient per month or year, and global budgeting

Expenditures for health services have been driven by inflation, demographic changes, the use of technology, and other reasons—chief among them the growth of public programs such as Medicare and Medicaid. The dedication of an ever-increasing proportion of GDP to health services (16.2 percent in 2007) raises questions about resource allocations to meet a range of needs. umerous initiatives to control expenditures have been largely unsuccessful in the long term, primarily because each has targeted only one part of the health services system. Barring major system changes, health services expenditures are projected to continue to increase. The amount of the GDP health expenditures absorb will depend on the strength of the economy. In a strong economy, the percentage of GDP could remain relatively constant or show an increase, whereas in a weaker economy, the proportion will depend on whether health expenditures match a slowdown or decrease in overall economic growth.

Chapter 8 – TCOs A & B

The Development of the Medical Profession in the United States

Managed care in the United States is predicated on this same principle: a patient first sees a primary care physician and then may be referred to a specialist

Advance Practice Nurses

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