unit 6
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causes of rising cost
• high prices charged • high administrative costs (maintaining buildings and personal salaries) • defensive medicine • cost of technological advances • specialist overuse • waste and fraud • high price of drugs comparatively
future causes of rising healthcare cost
• growth of aging population -declined health in youth -decrease in healthy lifestyles
non-profit healthcare institutions
• healthcare for all • operate as charities • exempt from most tax • pays SS and Medicare taxes
proprietary (for profit) healthcare institutions
• same manner as for profit businesses -pay local, state, and federal taxes ex: community health systems, community Corp of America, tenet healthcare
governmental healthcare institutions
-same manner as for profit businesses -pays local, state and federal taxes ex: Austin state hospital, Texas health resources Baylor medical system
historically paid for healthcare with
cash, vegetables, meat, firewood
fee for service plan
-patient pays premiums -physician determines actions taken -insurance pays for services **not cost effective
direct pay payment methods
-pt. pays for costs out of pocket -may use services more carefully -catastrophic when costs exceed pt. ability to pay
private insurance payment method
-individual/employer purchases insurance -employee usually pays some costs -many plans have varying coverage
government plans payment methods
funded by govt. agency ex: -healthcare for military personnel and their families -veterans administration hospital system -medicaid -medicare
medicaid
-20% of US healthcare spending -reg and partly govt funded -coverage by private managed care plans in contract with state -large portion of nursing home expenses
medicaid eligibility
-low income -children and their parents -pregnant women -disabled people -elderly people needing things not covered by medicare
income included in Medicaid for one
$16,970-$25,520
income included in Medicaid for two
$22,929-$34,480
income included in Medicaid for three
$28,887-$43,440
income included in Medicaid for four
$34,846-$52,400
medicare
-established 1965 -part of social security administration -health insurance for people 65+ -charged monthly premium, deductible, and coinsurance
Medicare coverage, A, B, C & D
Part A: hospitalization Part B: Outpatient services Part C: Medicare advantage plans Part D: prescription drugs
veterans health administration
-largest integrated U.S. healthcare system -all vets meeting criteria (including service-related disability) entitled to VA healthcare
what is managed care?
organizations negotiate with providers to form networks
goals of managed care
-affordable healthcare -high quality healthcare -discourage unnecessary costs -eliminate procedure duplication -earn profit
HMO
-must stay in network -must have PCP -must have referral to see specialist -out of pocket expenses set (low copay) -must submit requests for special care
PPO
-not required to stay in network -PCP not required -no referral necessary -more expensive -more provider choice -can visit providers outside of preferred list (more expensive)
EPO
-exclusive provider network -HMO/PPO hybrid -only in network services/ hospitals covered EXCEPT in emergency -no referral needed to see specialist -employers can tailor to employee needs