Paying for healthcare

• ancient Greeks and Roman • modern is in early 20th century

• first created in 1923 • only covered memebers expsnesed at single hospital- Baylor Hospital • Provided H for teachers at pre-paid monthly rate • creation of blue cross/ blue shield • forerunner of today’s HMOS

• as an incentive to recruit to workers because they were prohibited from raising wages

• became very popular in 1960s • payment method in which doctors, hospital, and medical practice charge seperately for each service they perform • pt or insurance company is responsible for the amt the healthcare provider chargers for the service • not cost effective for most

• non-profit: provide healthcare for all, aualify as charities, exempt from most taxes, do pay SS and medicare taxes • proprietary-for profit: community health systems, community corporiation of America, Tenet Healthcare • Governmental - VA, Austin State Hospital, Texas Health resources, Baylor Medical System

• type of system where provider don’t participate in any insurance reimbursement • they fix prices and charge a set monthly fees to pt regardless of the number of visits

• managed care is a type of private insurance • purchased by paitents • primarily provided by your employer as part of your benefit package • purchased in “bulk” by employers to provide to their employees

• services paid by government agency • Medicare and Medicaid

• US spends more per capita than other countires but does not have the highest success or satisfaction rates

• high prices for healthcare services and goods • significant adminsitrative costs (costs of maintaining buildings and personnel salaries) • defensive medicince • cost of technological advances • overuse of specialists • waste and fraud • high price of drugs relative to other products • high costs to develop

• growth of aging population • decline health in young • decrease in healthy lifestyle

• bill and code correctly (International Classification of Disease (ICD-10), numbers assigned to diseases and conditions, used to determine and justify charges by providers), Current procedural termin ology (CPT code, used to document and report all types of services) • DRGs - efforts impsoed by government and managed care to lower healthcare costs

• largest integrated health care system in US • serves veterans who meet certain qualifications

• Federal INSURANCE program • health insurance for ppl 65 and older and disabled persons • charges monthly premium • covers 80% of approved charges • paid by a trust fund, funded with payroll taxes • same program nationwide • pt pay deductibles and for part of coverage • types: Part A: Hospitalization Part B: Outpatient services Part C: Medicare advantage plans Part D: Prescription drugs

• Federal and State ASSISTANCE program • public health insurance program for low-income and disabled persons • partly funded by federal governments • administered and differs by states • funding differs slightly from state to state • covers large percentage of nursing home costs • provides medical coverage to needy individuals • based on income level • pt pays very little or no part of coverage • participants receive regular dental and vision exams

• benefits ppl with disabilities • prescription drug coverage • outpatient hospital care • inpatient hospital care

• Serves as a benefit that pays for medical care for employees who are injured or become ill because of their jobs

• Serves as a benefit that pays for medical care for employees who are injured or become ill because of their jobs

• designed to decrease out of pocket expenses for healthcare services • organizations negotiate with providers to form networks • aims to: provide affordable healthcare, ensure high-quality care, discourage unnecessary costs, eliminate duplication of procedures, earn a profit

• eligibilty depends upon continous employment • employees must work at least 20 hours or more per week • most companeis ahve awaiting peroids before insurance beeifts r available • pre-existing conditions may be ineligible

Health Maintenance Organization • Must stay in network • Must select a PCP • Must have referral to see specialist • Out of pocket expenses are set • copay is often low • Specialty care must be submitted to HMO for approval – may be denied

Exclusive Provider Organization • Must stay in network -PCP not required • No referral necessary

Preferred provider organization • Not required to stay in network • PCP not required • No referral necessary • More expensive • Wider range of providers • May visit doctors outside the list of preferred providers(out of network) • more expensive

• Point of Service • Similar to PPO • PCP IS required • Referral IS needed to see specialist • Lower Cost than PPO but more expensive than HMO • Wider network of providers to choose from • Out of network care is allowed