health law II outline - krause

health law II outline - krause - I Introduction A Problem...

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I. Introduction A. Problem with US Health Care is that it varies throughout the country B. Wickline v. State 1. Insurance not liable for patient’s loss of leg due to premature discharge from the hospital because insurance refused to pay. a. Utilization Review: prospective vs. retrospective i. Prospective: must get okay for procedure BEFORE the procedure/stay/etc. ii. Retrospective: go through with procedure, insurance might not pay for it 2. Insurance companies only liable if they truly interfere with the doctor/patient relationship 3. Doctor can be liable for complying with insurance if it goes against the patient’s best interest C. Overview of Insurance and Managed Care 1. Insurance: a. IRC allows employers to claim health insurance premiums as business expenses and doesn’t tax the premiums to employees as income b. Insurable Risks i. Uncertainty as to whether loss will occur If it does, it will be a loss outside of control of insured ii. Loss produced by risk must be measurable iii. Must be a sufficiently large number of similar insured units to make losses predictable iv. Loss must be signification v. Low probability a very high loss will occur c. Rate Making within Insured Group i. Likely morbidity & severity ii. Community Rating 1 premium for entire community o More expensive for the healthy o Assures everyone has health care iii. Experience Rating Premium customized to insured based on history Less expensive for healthy people d. Adverse selection: persons with poorer health apply for insurance moreso than healthy people, and that raises insurance costs. Therefore, healthier people will be encouraged not to get insurance. e. Favorable selection: selecting people who probably won’t need the insurance based on their history. They’ll be able to offset the costs of those higher risks f. Moral Hazard : fear that people with insurance are going to be less careful 2. Managed Care: a. Began in 1930s: i. Indemnity insurance They’ll pay you back for what you spend ii. Blue Cross & Blue Shield 1930s creation discount for going to doctor/hospital in network o Community Rating for premiums
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Today more like private insurance o Experience Rating for premiums b. Parts i. Middleman between patient and doctor ii. Limited network of providers focused on primary care physician as gatekeepers to specialists iii. Prepaid fixed fees iv. Quality and cost control mechanisms See Wickline and utilization review v. Emphasis on preventive care vi. Financial incentives for doctors to be at risk Make sure they aren’t ordering too many tests or spending too much on patients vii. Factors Risk sharing Administrative oversight Restriction on networks D. Defining Sickness 1. Illness: “when a condition is such that in its probable and natural progression it may be expected to be a source of mischief, it may reasonably be described as a disease or an illness” II.
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