2Chapter ObjectivesIdentify the major concerns with the health care system in the united States.Explain fee-for-service indemnity and prepaid health plans.Briefly describe the purpose and concept of insurance.Define the term insurance policy.Briefly describe the State’s Children’s Health Insurance Program (SCHIP).
3Chapter ObjectivesExplain the insurance policy terms deductible, co-insurance, co-payment, fixed indemnity, exclusion, and pre-existing condition.Explain what is meant when a company or business is said to be self-insured.List the different types of medical care usually covered in a health insurance policy.
4Chapter ObjectivesBriefly describe Medicare, Medicaid, and Medigap insurance.Briefly explain long-term care health insuranceDefine managed care.Define the terms preferred provider organization (PPO) and exclusive provider organizations (EPO) and explain how these organizations function.
5Chapter ObjectivesBriefly describe the two main organizational models of health maintenance organizations (HMOs).Explain point-of-service, physician-hospital organizations, and Medicare risk contracts.Identify the advantages and disadvantages of managed care.Identify the strengths and weaknesses of national health insurance, the Canadian health care system, and the Oregon Health Plan.
6Introduction How consumers obtain health care services How services are paidIssues of concernaccessqualitycost
7Access and Paying for Health Care Limited Availability & Accessibility of ServicesLack of health insuranceInadequate insurancePovertyU.S. Health Care Coverage44 million Americans uninsured or underinsuredLack Primary Care Access
8Access and Paying for Health Care Medically indigent or Working Poorincome above the poverty levelpoorest of the poor are usually covered by Medicaid
9Access and Paying for Health Care U.S. $3,900 per capitamore than any other nationSources of PaymentConsumers (19.6%)Third-party paymentsprivate insurance companies (33.1%)Public/governmental insurance (43.6%)Other private funds (3.7%)
11Access and Paying for Health Care Fee-for-servicemeans that the patient (1st party) either pays the physician, another health care professional, or pays the facility (2nd party) for services renderedPrepaid health carecapitation systemco-payments
12Third-Party PaymentBegins with providerFiling a claim
13Health Insurance Risk and cost spreading System of 3rd party payments in which a fee for service is paid by a 3rd party,an insurance company or government agency, which has collected the funds as insurance premiums or taxesChildren’s Health Insurance Program
15Health Insurance Policy PremiumsRegular periodic paymentsDeductibleamount of money that the beneficiary must pay before the insurance company begins to pay for covered servicesCoinsurance or Copaymentthe portion or % of insurance company’s approved amounts for covered services that the beneficiary is responsible for paying
16Health Insurance Policy Fixed indemnitymaximum amount an insurer will pay for a certain serviceExclusiona specified health condition is excluded from coveragePreexisting conditiona medical condition that carries a higher-than-average risk; a health problem you had before becoming insured..
17Types of Health Insurance Coverage Hospitalizationinpatient hospital expenses including room, patient care, supplies, and medicationsSurgicalsurgeons’ feesRegular medicalnonsurgical service provided by health care providers. Often has set amounts.Long-term carearray of supportive services
18Types of Health Insurance Coverage Major medicallarge medical expenses usually not covered by regular medical or dental coverageDentaldental proceduresDisabilityincome when insured is unable to work because of a health problemOpticalnonsurgical procedures to improve vision
19Trends in Insurance Coverage More complex plansIncreasing diversity of productsDelivery of care through networksShifting financial structures and incentivesManaging utilization
20Cost of Health Insurance Cost of insurance mirrors cost of careTwo major factorsrisk of the groupamount of coverage providedSelf-Insured Organizationscontrol cost of insurance
21Government Health Insurance Medicare65 years of age & olderdisabled persons who entitled to Social Security benefitsadministered by Health Care Financing AdministrationPart A - Hospital Insurancemandatory & provided without a premiumhas deductible & coinsurance provisionsPart B - Medical Insurancevoluntary & premium financed 75% by government
22Government Health Insurance Controlling costsprospective pricing systemdiagnosis-related groupsMedicare + ChoiceMedicare Managed Car PlanMedicare Private Fee-for-Service planMedicaidpolicy for the poorEligibilityfor the programs is determined by each Stateno age requirements
23Supplemental Health Insurance Medigapis a supplemental insurance program specifically designed for those on Medicare10 standardized plansFederal government mandates a standardized policyOther Supplemental Insurancedisease specificfixed indemnity policiesLong-term care insurance
24Managed Care Preferred Provider Organizations Exclusive Provider OrganizationsHealth Maintenance OrganizationsStaff model HMOsIndependent practice association modelPoint-of-Service OptionPhysician-Hospital OrganizationMedicare + ChoiceMedicaid and Managed Care
25Staff ModelSalaried physicians provide services only to HMO members. Physicians are housed in the building by the HMO & work only for the HMO.
26IPA modelIPA - individual physicians contract with an HMO to provide care for members. Providers can contract with other HMOs and/or maintain a private service. Most in the US.
27Advantages and Disadvantages of Managed Care Benefits beyond fee-for-service systemcomprehensive benefitsevidence-based high quality carewell-documented servicesintegrated delivery systemsaccountabilityConcernsact of confidencedelays in receiving carecannot understand billsbelieve charges are based upon coverage
28National Health Insurance Canadian Health Care Systempublic financed, privately deliveredeach provincial and territorial authority is responsiblecombination of taxesfee-for-service provided; government only payerStrengthsno one is without health insuranceequity across income groups
29Oregon Health Plan Revised Medicaid Coverage Addresses cost Prioritization Process709 Services reduced to 587Allows every Oregonian coverage
30Health Care System: Function Chapter 14Health Care System:Function