Study Guide- Final Exam Online (1)

HCD 303: Global Healthcare Systems Key Terms: ▪ System a set of connected things or parts forming a complex whole ▪ Quality how good or bad something is ▪ Access a person's ability to get care or coverage ▪ Cost financial burden of a medical intervention ▪ Universal coverage all residents have coverage ▪ Social Solidarity the principle that governments have an obligation to ensure that every citizen has access to all social services including healthcare ▪ Subsidiarity the principal belief that matter of government responsibility should be handled at the lowest level of government that makes operational sense ▪ General reciprocity the principal belief in giving to something knowing that you may not get an immediate returned benefit ▪ Centralized Organized at the federal level ▪ Decentralized Organized at the regional or state level ▪ Public Health Services/Insurance public, government run ▪ Private Health Services/Insurance private, privately run Only those who make over ~$70,000/year qualify The premium is set by your performance on an individual health assessment ▪ Copayment The set dollar amount that you must pay at the point of service ▪ Coinsurance The set percentage of the bill that must be paid at the point of service ▪ Deductible The amount that must be paid out-of-pocket annually, before insurance coverage kicks in ▪ Sickness funds ~130 sickness funds today (although this number is continually dropping) Covers ~ 86% of the country's population Membership is mandatory Must pay a legally mandated premium of 14.6% of their income (through payroll deduction) Split between employer and employee Percent of premium is determined by income ~11% of the population opts out of the SHI and opts for Private Health Insurance (PHI) Percent of premium is determined by health assessment and is risk-adjusted ▪ Safety net Children under 18 years of age exempt from all cost-sharing Adults: Annual cap equal to 2% of household income Annual cap lowered to 1% of household income for qualifying chronically ill people Unemployed contribute to SHI in proportion to their unemployment entitlements; For long term unemployed government contributes on their behalf ▪ Cost-sharing Outpatient Prescriptions: $6.40 - $12.70 Inpatient Stay: $10.00/day (first 28 days/yr) Rehabilitation Stay: $10.00/day (first 28 days/yr) Deductibles: vary by sickness fund plan Preventative services do not count towards deductible ▪ Subsidy government assistance ▪ Health Financing it is the function of a system concerned with the mobilization, accumulation, and allocation of money to cover the health needs of the people, individually and collectively, in the health system ▪ Health Spending The percent of money spent on healthcare every year, in relation to the total amount spent throughout all industries in the same year ▪ Fee-for-service A payment model where all healthcare services, products, and prescription medications are unbundled and paid for separately. incentive: Overtreatment, provide more services, testing, and treatments that are billable through an ICD-code.

▪ Per Diem payment model that reimburses organizations and/or providers based upon the number of days treatment was given ▪ Pay-for-performance A payment model that reimburses healthcare organizations and physicians who achieve, improve, or exceed their performance on specified quality and cost measures, as well as other benchmarks. incentive: Measure of performance metrics, Incentives can be financial or non-financial, Adherence to process ▪ Salary Physicians are paid a predetermined salary based upon their level of expertise and experience. incentive: No incentive for overtreatment, Provide the best treatment, regardless of ICD-code to the patient, there is also no direct incentive to work hard. ▪ Bundled payments (DRG, EDGR)DRG - A prospective payment model in which hospitals are reimbursed with a fixed fee regardless of the actual costs. Includes hospital expenses only. ACA required 30-day readmission penalty DRG Incentive - Reduce length of stay, Discharge appropriately, Keep costs to a minimum EDRG - An EDRG is another form of a bundled payment. The bundled payment = hospital + all physician payments + longer period of time (e.g. 6 - 12 months after hospitalization). The EDRG acts as a forcing function - encouraging physician and hospital collaboration on improving both patient outcomes and cost. Reference Pricing - Reference Price = the payment amount now going to medical centers with high quality and low cost Medical centers can charge more than reference price Patients told which medical centers charge more than reference price If patient chooses higher cost medical centers, patient pays the difference between reference price and medical center price ▪ Capitation A prospective payment model where the hospital or provider is paid a contracted rate per-member- per-month, regardless of the number of services provided. Rates are typically (but not always) risk-adjusted Incentive: Keep the patient healthy and living their daily lives in their own home, keep patient out of the hospital/clinic, freedom to provide non-traditional healthcare services ▪ Uniform Fee Schedule It refers to the amount of services that each provider can administer within each quarter Key Concepts: ▪ Components of a healthcare system people, parts, inter-relationships, and culture ▪ US rankings in The Legatum Prosperity Index report, Bloomberg Business report, & Commonwealth Fund report 1. 19th 2. 54th 3. 11th ▪ Goals of a healthcare system (3) 1. high quality 2. low cost 3. easy access ▪ How do you measure the various goals? Life expectancy quality of care patient outcomes patient safety patient satisfaction cost of care access to care