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Primary prevention?
Remove disease causing agents from the environment; treats populations
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Preventive?
Direct intervention to detect or or prevent (e.g., screening); patient is ambulatory
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Primary care?
initial diagnosis and treatment; daily, routine needs; patient is ambulatory; point at which the patient enters the health care system (e.g., a cold)
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Secondary care?
More specialized; more serious problems; ambulatory or overnight hospitalization (e.g., back surgery)
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Tertiary care?
Very specialized; most serious problems; complex care; almost always overnight in hospital (e.g., serious cancer operation)
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Illness?
Is defined by the patient- feel good, then a significant change for the worse, then seek out help
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Disease?
Is defined by the professional- a pathological process
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Sickness?
Is a social status conferred by others- they agree someone is sick, should not be blamed, should be exempt from normal tasks, and should try to get better and use the professional system
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Health?
Is complete well being- an ideal to strive for; can try to prevent/detect as well as treat disease
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Licensure?
Government grants permission to engage in an occupation or use a certain title; usually requires exam (e.g., Pharmacist)
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Registration?
Qualified individual listed on an official roster maintained by a governmental or nongovernmental agency (e.g., RPh; MT[ASCP])
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Certification?
Nongovernmental agency grants recognition to an individual that possesses certain qualifications (e.g., Board Certified Physician or Pharmacist). Testing may be required.
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Accreditation?
Nongovernmental agency gives stamp of approval to health care institution (e.g., JCAHO and hospitals) or health professions education program (e.g., ACPE and colleges of Pharmacy)
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Long Term Care?
Various services provided by various professionals in various settings to those with temporary or permanent functional disabilities of a physical or mental origin, intended to promote or maintain functional independence- not to cure
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Health insurance?
Health insurance is protection against the costs of hospital and medical care arising from illness or injury (plays a big role in shopping for health care because in addition to being essential and expensive, health care is uncertain)
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Rating?
Rating is a continuum with community on one end and experience on the other (it's how insurance companies decide which group of people will serve as the basis when deciding a premium); can be either community rating or experience rating
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Community rating?
In pure form, community rating might be when a single premium is calculated for everyone in the United States based on average expected utilization.
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Experience rating?
In pure form, experience rating might be when a premium is calculated for each individual based on their health and utilization history.
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Deductible?
The amount the insured has to pay for covered services before benefits become active (e.g., a yearly cost)
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Co-insurance?
Insured has to pay a percent of the reimbursement (e.g., 20%)
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Co-payment?
A flat amount the insured has to pay for each utilization event (e.g., $5 per prescription)
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Indemnity benefits?
Patient pays provider, and insurer reimburses patient (shoebox effect)
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Service benefits?
Insurer pays provider directly
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Premium?
Periodic payment required to keep policy in effect
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Capitation?
A fixed amount of money (flat payment) paid to a physician per patient per unit time, regardless of whether the patient is ill or well;
it is a system of payment based on the physician's patients, rather than the services provided to each patient. (Pure (simplified) example: Doctor gets paid $X per year for treating #X amount of patients, no matter what services provided)
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Health Maintenance Organization (HMO)?
-HMOs combine financing & delivery
-A pure HMO owns its own hospitals and pays its physicians a salary
-Contractual arrangements (capitation) are often used to foster the incentives created by a pure HMO
-Benefits are usually comprehensive, and cost-sharing minimal
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Preferred provider organization (PPO)?
-Grew out of the “fee-for-service” system
-Preferred provider gives discount to insurer when patient uses that provider
-Patient cost-sharing lower if preferred provider used
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Point of service plans (POS)?
-Grew out of the HMO system
-Patients wanted more choice
-If patient leaves network, cost-sharing is higher
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Managed care?
Managed care in the most general sense means "overseeing the physician's decisions; managed care does not equate with putting the provider at economic risk.
Characteristics include:
-Primary care physician as gatekeeper (responsible for ALL primary care, refers to specialists, oversee and coordinates care)
-Utilization oversight (prospective or retrospective, prior authorization, second opinion)
-Networks (more potential for management control)
-Consumer controls (waiting times, case management, self-care)
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What are the major causes of death in the U.S.?
- 1- Diseases of the heart
- 2-
Malignant neoplasms (cancer)- 3-
Cerebrovascular diseases (e.g., stroke)- 4-
Diabetes- 5-
Chronic lower respiratory diseases (e.g., COPD)- 6-
Accidents- 7-
Alzheimers- 8-
Influenza and Pneumonia
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How much is spent on health care?
2.3 trillion total
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What percent of the GDP is spent on health care?
16.2%
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How much do we spend per capita on health care?
$7,681 per capita (U.S. population is approximately 302 million)
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What percent of the total, for health care spending, is for hospitals? physicians and clinical? drugs? nursing homes? administration?
- Hospitals= 31%Physicians and clinical= 21%Drugs= 10%Nursing homes= 6%Administration= 7%Other= 25%
(Other very large due to redefinition of the categories)
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What is the annual percentage growth rate for drug spending?
Overall health spending grew from 4.4-7% (from 2007)
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How many Americans do not have health insurance? How many are underinsured (defined as unable to pay what insurance won't)?
Uninsured = 44 million in 2009; this is about 15% (U.S. census bureau NCHC)
Underinsured= 25 million in 2007
- - 11% of those with incomes < $40k
- - 31% of those with incomes < $20k
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What factors determine a person's health status?
- Biology (genetics, aging, internal systems)
- Environment (physical, social, psychological)
- Lifestyle (consumption, leisure, employment)
- Health system (preventive, curative, restorative
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What happens when an individual starts to feel like they are ill?
They:
- - Have a perceived need
- - Go to the "lay system" for help
- - Adopt the sick role
- - Enter the professional system
- - Are diagnosed; physician decides
- - Are treated (therapy); physician decides
(There are outcomes of the process)
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Who makes up the "three-legged stool"?
1) Governing Board (Board of trustees or directors)
2) Administrator or Chief Executive Officer (CEO)
3) Medical Staff
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Skilled Nursing Facility (SNF)?
- More intensive nursing care than ICF
- Bridges the gap between hospital and home
- Shorter term than ICF
- Medicare and Medicaid pay
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Intermediate Care Facility (ICF)?
- Less intensive nursing care than SNF
- More custodial care
- Longer term than SNF
- Medicaid and self-pay dominate
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Approximate Spending Percentages in
2008 (CMS)
- Medicare: 19%
- Medicaid/SCHIP: 15%
- Other public (e.g. VA): 12%
- Private insurance: 35%
- Out-of-pocket: 12%
- Other private (e.g. in-plant): 7%
(Medicare and Medicaid = about 1/3; Public = almost ½)
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Medicare Part A
- Financed by payroll taxes
- Mainly for hospitals and skilled nursing facilities, home health, and hospice
- Has deductible per benefit period
- ICF not covered
- Hospital deductible per benefit period: $1100
- Hospital co-payments per benefit period: $275/day for the 61st- 90th day, and $550/day for the 91st-150th day
- Skilled nursing facility co-payments: up to $137.50/day for the 21st-100th day
- Uses PPS (prospective payment system) as a payment system
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Medicare Part B
- Financed by premiums and general revenue
- Mainly for physicians and outpatient lab tests, x-rays, etc.
- Has premium, deductible, and co-insurance
- Voluntary
- Premium: $96.40/month (may be higher depending on your income)
- Deductible: $155/year
- Co-insurance rate: 20%
- Uses RBRVS (resource-based relative value scales) as a payment system
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Medicare Part C
The HMO and Medicare + Choice programs are now considered together as Medicare Advantage.
- Medicare enrollees can choose to join a Medicare-approved HMO if there is one in their area. If so, the government pays the HMO a premium, and the HMO takes responsibility for the patient’s care. Patient still pays Part B premium. Cannot be charged more than Part B premium.
- Medicare HMOs must cover at least what traditional Medicare covers and often cover more to attract patients. HMO was only option.
- Later, the Balanced Budget Act (BBA) of 1997 created Medicare + Choice (was called Part C)
-- Allows enrollees to select other, more loosely defined managed care and other options in place of traditional Medicare. (PPO and FFS plans-not just HMO)
-- Under this approach, which is intended to give enrollees more choices and foster competition, plans can charge enrollees premiums beyond the Part B premium. Benefits can vary, too.
- This complicates decision-making for the elderly.
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Medicare Part D
•Medicare Prescription Drug, Improvement and Modernization Act was passed into law in November 2003.
•New law includes a voluntary outpatient prescription drug benefit that took effect in January, 2006 = Medicare Part D.
Eligibility:
- - All Medicare beneficiaries
- - Benefit is voluntary
- - Monthly premium average is in the $12-$32 range (could be $0 – could be much more)
- - Government pays additional amount to plan
- --------------------------------------------------------------
- - Drug benefits are provided through private plans, which will bear the risk
- Plans are chosen by the beneficiary and must provide coverage that is actuarially equivalent to the standard coverage
- dollar value of coverage under a Part D plan is equal in dollar value under another plan is equal to dollar value of standard plan
- 2 different ways to do it:
- - Traditional Medicare plan with an add on stand-alone Rx drug plan (PDP)
- Medicare Advantage Plans (e.g. PPO, HMO)
Standard coverage in 2009:
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Drug classes NOT covered under Medicare Part D?
•benzodiazepines; fertility drugs; drugs for anorexia, weight loss or gain; cosmetic or hair growth drugs; symptomatic relief of cough and colds; most prescription vitamins or minerals; OTCs; barbiturates
(other than classes NOT covered, at least two drugs in each therapeutic class or category based on USP standards)
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A "Best Practice" plan in Medicare part D includes which classes of drugs?
- antidepressants
- antipsychotics
- anticonvulsants
- antiretrovirals
- immunosuppressants
- antineoplastics
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