Section 1
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Define: Social Justice
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Date created
Mar 1, 2020
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Section 1
(50 cards)
Define: Social Justice
Healthcare is a social resource and society is collectively responsible for health. Focused on fairness
Is insurance consumer driven or provider driven in the US?
Provider driven. Opposite than in Europe.
Define: Medical Loss Ratio
Part of the ACA (p 336 in textbook): requirement that 80% of premium dollars in individual market be spent on care and quality improvement
Describe: Self-Insured EBI
Company insures itself rather than purchasing insurance Contract with 3rd party to administer the benefits (ie. Pay claims) Tend to be large employers, often with employees in multiple states NOT regulated by states; regulated by federal government under ERISA
What is the AMA (American Medical Association)?
29% of MD's belong, lobby. often dominated by specalists. Opposed Medicare and all governement involvement in healthcare. Worried this would drive down their reimbursements.
Why did the AMA oppose Medicaid/Medicare?
Thought it would lower their reimbursement rates. Socialism. Skeptical of government involvement in health care.
Define: Market Justice
Healthcare is an economic good and should be controlled by market forces. Individuals have a responsibility for their own health. Focused on efficiency
Define: Modified community rating
Part of the ACA Adjustments allowed for family coverage, geography, age, and tobacco use---No adjustments permitted for pre-existing conditions, occupation, gender, duration of coverage, credit worthiness!
What were the Soumerai studies from 1980s?
People stopped taking important medications when Medicaid medication payment strategy changed Individual impact of cost-sharing
What was the outcome of the Whitehall Study?
Those with lower civil service grades had higher mortality rates. Shows that income/workplace/social status/social determinants have an income on health
Define: Co-insurance
a fraction of the cost of a service that the insured person has to pay Percentage you have to pay for whatever procedure/visit
Fuchs Article: How does the US compare with other OECD countries?
Health expenditures (higher), health outcomes are more unequally distributed
Medicare Part C
Operates somewhat separately from the rest of Medicare--if you opt for C, you must first qualify for A,B but you opt to pay a bit more) Managed Care Used to be called Medicare + Choice, now re-branded MedicareAdvantage (2003) Higher Premiums (pay more money per month, but better coverage than A or B) Includes Drugs C is a private alternative to A and B In C, a private entity/private insurance company gets money (that would usually go to part A, B) from the government from General Revenue, State taxes, etc.
Define: Guaranteed issue:
Part of the ACA insurers must accept all applicants in individual and group markets, regardless of health status, occupation, or other risk factors
Mackey (Whole Foods Article): Mackey argues that markets work IF you do what reforms?
You remove legal obstacles Equalize tax laws for employer-provided and individually-owned insurance Repeal state laws preventing cross-state competition Repeal government mandates about what insurance companies must cover
What is the largest driver of care seeking and healthcare costs?
Symptoms
Overall themes of the ACA
More preventive care and disease management, more focus on mental health and substance use disorder services Required coverage of "Essential Health Benefits
Define: Single risk pool
Part of the ACA claims experiences of all enrollees in individual plans pooled; reduces risk that sicker people will pay higher premiums
What is the biggest difference between the US and other OECD countries in terms of healthcare?
Health insurance! Most people under 65 have private HMO based insurance
Define: Premiums
The amount you have to pay up front to buy insurance
When did Employer Based Insurance originate?
After WW2. It is now deeply engrained in the US tax code and and management/union
Define: Cost Sharing
An attempt to counterbalance over utilization; make patients have skin in the game A way for insurance companies to counteract Moral Hazard (limiting the amount of healthcare that you use) Examples: Premiums Deductibles Co-Pays Co-insurance
What is the current trend in cost sharing?
To INCREASE it
Krugman Article is a summary of an Arrow article. What does Arrow argue?
markets don't work well in healthcare, because: You don't know when you'll need insurance You can't comparison shop or rely on experience Insurance companies' interests not aligned with yours
Medicare Part D
Drugs 2003, part of the re-branding Private Insurance based (government didn't want to build a whole new infrastructure, so they use private insurance companies) OPTIONAL: you have to opt into it States have to opt into it as well, but all 50 have. Financed by STATE payments (unique to and premiums, Federal General Revenue
What is more important in determining medical status, healthcare or social determinants?
Social determinants
What is the thesis of Linking Clinical Variables Article (by Prof. Wilson)
This article proposes that physicians focus more on overall health-related quality of life, rather than biological and physiological variables alone.
What is "pre-payment"?
The concept of paying for care before you receive it
Describe: EBI
EBI has risk pooling: risk is more spread among the population EBI has underwriting (assessing risk) for groups, not individuals; less expensive because you don't have to assess the risk of each individual EBI has less of an adverse selection problem EBI has huge public subsidies because company and individual contributions to health insurance are tax exempt It has a regressive effect (higher income people benefit more) It reduces government revenues It contributes to overutilization
Define: Moral Hazard
when a party insulated from financial risk behaves differently than it would behave if it were fully exposed to the financial risk (ex: freshmen 15) If you have insurance, there is a concern of over utilization
Fuchs Article: WHY does the US have higher health expenditures and unequal distribution of health outcomes?
historical distrust of government, reluctance to achieve equal outcomes, political system influenced by special interests
Define: Deductables
The amount that an individual or family has to pay out of pocket before insurance takes effect You pay 100% of your medical costs until you reach your deductable
What does the US do poorly in terms of healthcare?
Ridiculously high costs Basic health outcomes - our infant mortality rates, potential years of life lost, obesity rates, hospital admissions for asthma, etc. are all worse than those of other OECD countries Value - we spend the most money on health care, but we don't have the best outcomes
Where do people UNDER 65 (don't qualify for Medicare) get their health insurance?
A variety of places: 2/3 have private 15% have Medicaid or other public 18% were uninsured (pre 2014)
Describe: State Licensing EBI
State regulated Employer pays premium for each employee, and plan assumes full insurance risk for employee Tend to be smaller employers (3-199)
When did private insurance originate
19th c. Europe
When did "prepayment" originate
During the great depression when the hospitals were worried they were not making enough money. Hospitals were empty because everyone was poor.
Medicare Part B
(think WALKING) outpatient Financed by federal, and premiums Lower premiums than C
What does the US do well in terms of healthcare?
Health research - the NIH receives a ton of funding and does great research Excellent specialty care at teaching hospitals Certain cancer screenings
What was the RAND Health Insurance Experiment
It was a study of the impact of cost sharing on utilization and health outcomes; patients and families randomized to different levels of cost sharing Findings: Cost sharing reduced utilization but did not result in worse health outcomes Justified low levels of cost sharing Population impact of cost-sharing
Define: Guaranteed renew ability
Part of the ACA insurers must renew people's coverage regardless of their health; unless person has committed fraud or has not paid
Medicare Part A Services
(think NO walking) Inpatient Hospital based Skilled Nursing Facility
Fuchs Article: What has changed about US healthcare system since 1950?
U.S. health care expenditures have risen rapidly Rise of third-party payment (insurance) instead of out-of-pocket payment Increased government role in funding health care Decline in inpatient care Shift in physician workforce: more females, specialists, hospital-based doctors New medical technologies
Main themes from the Sensipar/Amgen Story
Influence of politics, lobbiest, money on healthcare. Sensipar exempted for two years from being under gov. control, at the cost of hundreds of millions to tax payers.
Who are the three players in the healthcare system?
Payers Providers Regulators
Define: Co-pay
a fixed amount that the insured person has to pay at the time a service is provided Flat Rate
What is the relationship between workers wages and health insurance costs?
Health insurance premiums are going up and workers contributions to premiums are going up at much higher rates than workers' earnings and inflation
Iatrogenic disease
Disease caused by physicians and/or medical care
What is the general trend of companies offering heath insurance?
Declining
How many people 65+ have health insurance?
Nearly everyone. Medicare.
Section 2
(50 cards)
Oregon Medicaid Experiment
Lottery to give extended access of Medicaid This: increased the rate of health care services utilized, raised rates of diabetes detection, lowered depression and lessened financial strain.
Community Rating
In a single risk pool, all people pay the same rate (some are sick and some are healthy). Everybody pays the same price regardless of your salary/pre-existing conditions. Not all EBI is community rating.
DHS: Disproportionate Share Hospitals
When an uninsured person is unable to pay and occurs a large amount of money on a hospitals, federal government
HSA
Pre-taxed dollars Doesn't get taxed You can use it for medical purposed Usually coupled with high deductible plans
What is the insurer perspective in Capitation?
way less financial risk, less direct involvement in delivery of services. because they are only paying a set fee per person.
What is PPS
Perspective Payment System
FMAP: Federal Medicaid Insurance Program
The Federal government pays for DSH. Program for the transfer of money from the federal government
Cost Shifting
Healthy people subside the sick people. Could also mean that the government takes more of the burden off of the insurance company. Breaking up disproportionate burden that some people caring.
What is the provider perspective in Capitation?
Way more risk, but the potential to make a lot of money. Might make providers more likely to stop doing expensive procedures and instead to do a lot of cheap/easy procedures to make a lot of money.
Gaureened Issue
You cannot deny health insurance to anyone ACA
Doughnut Hole
Only refers to prescription drug costs Part D of Medicare $3000-$6700 Initially, you have to pay out of pocket Between $3000 and $6700, there is no insurance covering you. This is referred to as the doughnut hole. The ACA is working to reduce this to 25%
Asymmetric Knowledge
YOU know more about your health than the insurance company, so the insurance company doesn't know what to charge you. pre-ACA, "cream skimming"
Experience Rating
Cost is based on how much the group cost last year.
Problem of Externalizes
Cost or benefit not reflected in price, but rather paid for by a third party. Negative Externalizes: pollution Positive Externalizes: vaccines
Point of Service
You must start in one place before you go to a specialist This is often mandated by HMOs
Reinhardt Article, "The Disruptive Innovation of Price Transparency..."
Why does the United States pay so much more money for health care? - we don't go to the doctor more - MUCH higher prices for services and providers
When was ObamaCare
2010
SCHIP
Covers children up to %200 FPL who don't qualify for Medicaid Federal government offers some reimbursement to the states for SCHIP
According to the Reinhardt Article, WHY does the USA have such a high price for healthcare?
- Fragmented insurance system that drives the cost up by setting benchmark prices. - Patients don't have a lot of skin in the game
ESI
Employer Sponsored Insurance Generally has risk pooling Huge public subsidies Mostly regulated by states (but companies can self insure to avoid state regulation)
What is the provider perspective in FFS?
There isn't rate control, but there is also no risk. Can always do more procedures, and then bill more money.
Death Spiral
TKTKTKTK
Modified Community Rating
No adjustments permitted for per-existing conditions, occupation, gender, duration of coverage or credit worthiness Under the ACA
First Modern Day Insurance program
Blue Cross/Blue Shield Merged in 1982
Individual Mandate
Everyone must buy health insurance or face a tax penalty
What year did Medicare start
1965
What is the patient perspective in FFS?
No restrictions for doctors or services, but could be over utilized. MDs doing unnecessary procedures.
episode bundling
one price for one procedure or illness, not a fee for each separate sponge etc.
MediGap
Private Insurance, but you can only have it if you qualify for A and B If you have A and B, but you are worried that you're paying too much for A and B, then you pay a monthly premium to MediGap, and it covers more of your A and B costs.
Manual Rating
Each person's risk is determined individually. The rate is based on what their risk is. From a manual. For example, if you are a woman, you might have to pay more. Again, medical underwriting is not illegal under the ACA excluding gender, smoking, family size.
Medical Underwriting
Combats asymmetric knowledge. Medical underwriters want to find out as much about you as they can to figure out how to charge more. The ACA makes this quite illegial, but is still allowed to charge more if you smoke, based on gender, and family size.
Lifetime Limit
If you reach a lifetime limit, (like 1mil dollars), then the insurance company no longer has to pay ACA made this illegal
Who is eligible for Medicare?
65+ End stage renal disease ALS (lu garighs disease) Disabled
"Patients Costs Sky Rocket..." Elizabeth Rosenthal Article
Seemingly minor procedures can rack up spending if it involves specialty doctors Specalists heavily engaged in lobbying Doctors in USA earn WAY more than MDs elsewhere--specialists specifically.
AMA
Fought universal medical insurance, because they believed that it was socialism, would make their wages go down
Blue Shield Insurance for Physician Visits
TKTK
Staff HMO
Providers get paid a salary by the insurance company and they work only for the insurance company.
What is the payer (insurer) perspective in FFS?
LOTS of risk. It could suddenly cost a billion dollars.
PPO: Preferred Provider
Where the HMO wants you to go. Probably costs less
Medical Loss Ratio
How much insurance company money goes towards the health care. Insurance companies think of paying for healthcare as bad. Frustrating for the consumer because they want their costs paid for. Creates conflict of interest
What is the thesis of the "America is Europe" article by David Brooks?
US has less social mobility than Europe US has a bigger welfare state In Europe, Governments directly offer healthcare to citizens. In USA, Federal government heavily subsidizes health care through giving employers a huge tax exemption to do so. The things that make the government in Europe seem big are because they are done publically. In USA, we do them in a back-door manner, through tax credits. These expenditures are HUGE, and hidden, and have BAD effects. Don't help the people who actually need help.
Risk Pooling
The more people you have in a pool, the more stable and predictable costs will be for the insurance company.
Continuum of Aggregation
How insurance pays doctors FFS (each thing costs a certain amount of money) Perdiem (per day of treatment) Episode Bundling (per illness) Capitation (per patient)--may cause providers to not provide for certain things (you get the same amount of patients for band-aids than big procedures so you get rid of the big procedures)
How common are medical bankruptcies?
The most common form of bankruptcy
What are the three main features of healthcare?
(low) Cost, (high) Quality and Access Mutually exclusive (you can't have all three)
Principal-Agent Problem
MD's are supposed to act as a patient advocate, but they also have a financial benefit to gain--i.e. if colonoscopies are very
Actuarial Fair Value
The risk of the event (percentage wise) times the cost of the event happening
When was the Medicare Modernization Act
2003 Created Part D Created Medicare Advantage (the re-branding of Medicare + Choice)
High Deductible Health Plans
Premiums are LOWER You have WAY more you have to pay out of pocket (in a normal year you will probably not meet your deductible) Often coupled with a Health Savings Account (HSA)
capitation
When insurers pay doctors PER person
Section 3
(37 cards)