Essentials of The U.S. Health Care System (Test 1)

Characteristics of Managed Care

-seeks to achieve efficiency by integrating the basic functions of health care delivery
-employs mechanisms to control utilization of medical services
-determines the price at which the services are purchased and how much providers get paid

The financing of a managed care organization is primarily based on...

Capitation

What is Capitation?

A payment mechanism in which all health care services are included under one set fee per covered individual.

What is Medicare?

Medicare is a U.S. government program focused primarily on the elderly

Why is the U.S. healthcare system considered to be imperfect?

Prices are determined by health plans rather than the interaction of the forces of supply and demand

What is the most dominant health care delivery system in the U.S. today?

Managed care

What is the major role of the U.S. government in the US health care delivery system?

To be a major financier of health care delivery for both Medicaid and Medicare

In a socialized health insurance system, health care is financed through

government-mandated contributions by employers and employees

In a free market...

...buyers and providers act independently

The social justice system emphasizes

community over the individual

What is medicaid?

Government program for the poor

Parties that act as key players in the US Health Care System

Large employers, government, and physicians

What is the primary reason for employers to purchase insurance plans to provide health benefits to their employees?

The U.S. does not have a universal health care system so employers purchase health insurance plans to fringe benefit for their employers.

How is the tax-supported national health care program in a national health care insurance system financed?

...

What is national health insurance?

a tax-supported mechanism in which the government guarantees basic package of health services to all citizens

Over the last decade, the hallmark of the US health care industry has been?

organizational integration to form integrated delivery systems or networks

America's safety net is for

the nation's vulnerable positions

The military medical care system is free for who?

active military personnel

Vulnerable populations

Poor, uninsured, and people of minority status

Result of growth in science and technology

More demand for new services

What is the social justice principle?

Emphasis is placed more on the well-being of the community over the inidividual

The United States spend more than any other developed country on health care, and costs have

continued to rise

Health care managers are needed to

manage and coordinate various types of health services

Main players in the private managed care sector

Licensed health maintenance organizations (HMOs) & preferred provider organizations (PPOs)

Role of MCOs (Managed Care Organizations)

Integration of health care components; Example: paying providers through capitation per head arrangement

Four key functions of managed care delivery

Financing, insurance, delivery, and payment

What is TriCare?

a program financed by the U.S. Department of Defense, which permits beneficiaries of military personnel to receive care from both private and military medical facilities.

The VA system

organized into 21 geographically distributed Veteran's Integrated Service Networks (VISNs)

Veterans Integrated Service Networks

Responsible for coordinating the activities of the hospitals and other facilities located within jurisdiction.

What is an IDS

A network of health care providers and organizations that provides or arranges to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the clinical outcomes and health status

The most important principles in delivering integrated care that us specific to vulnerable populations

An emphasis on primary care, coordination of all care (including behavioral, social, and public health services), and accountability for population health outcomes.

Long-term care

medical and non medical care that are provided to individuals who have chronic health issues and disabilities that prevent them from doing regular daily tasks; Medicare does NOT cover this; Medicaid covers several different levels of LTC services but pers

Mission of the public health system

To improve and protect community health

ACA provisions for public health care efforts

Established Prevention and Public Health Fund to provide expanded and sustained national investments in prevention and public health, to improve health outcomes, and to enhance health care equality

Main characteristics of the U.S. Health Care System

-No central governing agency and little integration and coordination
-Technology-driven delivery system focusing on acute care
-High in cost, unequal in access, and average in outcome
-Delivery of health care under imperfect market conditions
-Government

Advantages of having a centrally controlled health care system

They are less complex and less costly; Global budgets are used to control total expenditures and govern availability and utilization of services.

Technology Driven and Focus on Acute Care

When technology and research increases, consumers and patients demand innovative and sophisticated care. Consequently, finances for such care shrink at much faster rate. Not enough emphasis is placed on public health and primary care which produce better

High in Cost, Unequal in Access, and Average in Outcome

Even though the U.S. spends almost 17% of GDP on health care , many residents have unequal access.

Who in the U.S. has access to health care services when needed?

Those with health insurance through their employers, those who are covered under a government-sponsored health care program, those who can afford to buy insurance out of their own private funds, and those that are able to pay for service privately or can

Imperfect Market Conditions

Health care in the U.S. is only partially governed by free market forces; described as being quasi-market; prices set by agencies external to the market and payer is MCO, Medicare, or Medicaid.

Perfect Market Conditions

Multiple patients and providers act independently; providers would be chosen based on price and quality of services; supply & demand