Transcript Unit 4 Health Insurancex

Health
Insurance
1:5 Health Insurance Plans
A- Health Insurance - without insurance, the
cost of an illness can mean financial disaster
for an individual of family
Example: Blue Cross-Blue Shield – premium is paid to the insurance
company and insured individual is covered for certain health care
expenses
B- Health Care Insurance Terms
1- Deductible
2- Co-insurance
3- Co-payment
amounts paid by the patient for
medical services before the
policy begins to pay
specific percentages of
expenses shared by the patient
and insurance company (80% 20%)
specific amount of money a
patient pays for a particular
service ($20 office visit)
C- Types of Health Insurance Plans
1- Health Maintenance Organization (HMO)
a) monthly fee or premium is paid
b) fee stays the same regardless of the amount of
health care used
c) Disadvantage: insured person required to use
ONLY HMO affiliated health care providers – if not
the patient pays the cost
2- Preferred Provider Organization (PPO)
a) usually provided by large companies or
industries to their employees
b) Industry or company forms a contract with
certain health care agencies to provide health
care at reduced rates
c) person restricted to specific hospitals and doctors
3- Medicare – pays 80% of services, patient pays
balance or has additional insurance
a) Federal government program
b) Provides health care for almost all persons over the
age of 65 and any person with a disability who has
received Social Security Benefits
c) Type A – hospital insurance – covers hospital services,
care provided by an extended care facility, home-health
care after hospitalization
d) Type B – medical insurance – pay premium for
doctor’s services, outpatient treatment, therapy, etc.
4- Medicaid – medical assistance program
a) Operated by individual states- government program
b) Usually pays for health care of individuals with
low incomes, children who qualify for public
assistance, and individuals who are disabled or
blind
5- State Children’s Health Insurance Program (SCHIP)
a) Established in 1997
b) Provides health care to uninsured children of working
families who earn to little to afford private insurance but
too much to be eligible for Medicaid
6- Worker’s Compensation – health insurance plan
providing treatment for workers injured on the job
a) In addition to providing payment for needed
health care, also reimburses the worker for wages
lost because of on the job injury
7- TRICARE (formerly called CHAMPUS (the Civilian
Health and Medical Programs for the Uniform
Services))
a) Provides health care for all active duty members, their
families, survivors of personnel and retired members of the
Armed Forces.
8- Managed Care – developed in response to rising
cost of health care
a) All health care provided to a patient must have a
purpose
b) Second opinion or verification is often required
c) HMOs and PPOs are the main providers of
managed care
1:6 Organizational Structure
A- Complex in larger facilities and simple in
smaller facilities
B- Always encompasses a line of authority or
chain of command
1:7 Trends in Health Care
A- Cost Containment – trying to control the
rising cost of health care and achieving the
maximum benefit for every dollar spent
B- Reasons for High Health Care Costs
1- Technological Advances
a) Heart, kidney and lung transplants can cost
hundreds of thousands of dollars
b) Computers that can examine internal body
parts can cost millions of dollars
2- Aging Population
a) Increases the use of pharmaceutical
products (medications)
b) Have more chronic diseases and need
frequent health care services
3- Increase in Health Related Lawsuits
a) Health care providers forced to obtain
expensive malpractice insurance
b) Health care providers forced to order
diagnostic tests even though they may not be
needed
c) Health care providers practice defensive
health care to avoid lawsuits
C- Methods of Cost Containment
1- Diagnostic Related Groups (DRGs)
a) One way congress is trying to control costs
for Medicare and Medicaid
b) Patients with certain diagnoses who are
admitted to the hospital are classified in one
payment group
c) Limit is placed on the cost of care and the
agency is paid a set amount.
2- Combination of Services
a) Done to eliminate duplication of services
b) Health care agencies join together or share
specific services so as to provide care to a
larger number of people at a decreased cost
per person
3- Outpatient Services
a) Patients receive care without being
admitted to the hospital
4- Mass or Bulk Purchasing
a) Buying equipment and supplies in larger
quantities at reduced prices by combining
purchases of different departments
5- Early Intervention and Preventative Services
a) Provide care before acute or chronic
disease occurs
b) Education, immunizations, regular physical
exams, easy access for all individuals to
preventative health care
6- Energy Conservation
a) Monitoring the use of energy to control
costs and conserve resources
b) Major expenses for every health care
facility are electricity, water and/or gas.
D- Home Health Care
1- shorter hospital stays and Diagnostic
Related Groups (DRGs) have created need
for providing care in the home
2- nursing care, physical therapy,
occupational therapy, respiratory therapy,
social services, nutrition and food service,
etc.
E- Geriatric Care
1- care for the elderly rapidly growing
2- large number of individuals living longer
3- adult day care centers, retirement
communities, long term care facilities, etc.
F- Omnibus Budget Reconciliation Act (OBRA)
1. 1987 – led to development of many regulations
regarding long term care and home health care
2. Requires:
b) continuing education, periodic evaluation of performance
and retesting if out more than 2 years
c) compliance with patients rights guidelines to
ensure rights are observed and enforced
G- Telemedicine
1. Uses video, audio and computer systems to
provide medical and/or health care services
H- Wellness
1- State of being in optimum health
2- Recognize the importance of exercise,
good nutrition, weight control and health
living habits
3- Factors and Ways to Promote Wellness
a) Physical wellness
c) Social wellness
b) Emotional wellness
d) Mental and intellectual wellness
e) Spiritual wellness
4- Holistic Health Care
a) Promotes physical, emotional, social, intellectual,
and spiritual well being by treating the whole body,
mind and spirit
I- Alternative and Complementary
Methods of Health Care
1- Alternative Therapies – methods of treatment
that are used in place of biomedical therapies
2- Complementary Therapies – treatment that
are used in conjunction with conventional
medical therapies
3- Examples of alternative/complementary
therapies
a) Chinese medicine practioners – ancient holisticbased healing practice based on belief that life
energy (chi) flows through every person
B) Chiropractors – believe that the brain sends vital
energy to all body parts through nerves in the spinal
cord – misalignment causes pressure to be placed on
nerves and disease results
4- Office of Alternative Medicine (OAM)
a) Established at the National Institute of Health in
1992 because of the increase use of alternative and
complementary therapies
b) Researches various therapies and determines
standards of quality care
J- National Health Care Plan
1- demand due to high cost of health
care and the large number of uninsured
individuals
2- one plan involves nationalized
medicine – government would pay for
all health services and levy taxes to pay
for those services
3- goal is to ensure that all Americans
can get health coverage
Assignment:
Complete the packet
“Unit 1 – Health Care Systems”