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QUIZ%201%20PREP - Q UIZ 1 PREP-Outlines of the first 2...

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QUIZ 1 PREP--Outlines of the first 2 chapters *CHAPTER 1: Major Characteristics of US Health Care Delivery OBJECTIVE OF CHAPTER 1 1. Provide a broad understanding of how health care is delivered in the United States THE PRIMARY OBJECTIVES OF A HEALTH CARE DELIVERY SYSTEM 1. To enable all citizens to receive health care services whenever needed--universal access 2. To deliver services that are cost-effective and meet certain pre-established standards of quality. THE QUAD-FUNCTION MODEL: FUNCTIONAL COMPONENTS OF HEALTH CARE DELIVERY 1. Financing--to purchase insurance, or to pay for health care services consumed 2. Insurance--to protect against catastrophic risk 3. Delivery--to provide health care services 4. Payment--to reimburse providers for services delivered SUBSYSTEMS OF US HEALTH CARE DELIVERY *Multiple subsystems developed through market forces or the need to take care of certain population segments 1. Managed Care (most dominant health care delivery system in the US today) Definition: A system of health care delivery that a) seeks to achieve efficiencies by integrating the basic functions of health care delivery b) employs mechanisms to control utilization of medical services c) determines the price at which the services are purchased, and consequently, how much providers get paid. Financing: private or public entities, but managed care enables these entities to better manage their health care dollars. Two types of financing mechanisms are commonly used: a) Capitation: For one set fee per member per month (PMPM) the MCO promises to deliver all needed health care services. b) Discounted fees: Insurance --MCO assumes risk and acts as an insurance carrier. Delivery --MCO arranges to provide health care services to the enrollees--either directly or through contracts. MCO implements various types of controls to manage utilization. Payment --MCO acts as a payer
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and disburses payments to providers based on capitation or discounted fee arrangements. 2. Military 3. System for Vulnerable Populations 4. Integrated Delivery System CHARACTERISTICS OF THE U.S. HEALTH CARE SYSTEM * Combined interaction of external factors such as political climate, stage of economic development, and technological progress influences the course of U.S. health care delivery 1. No Central Governing Agency; Little Integration and Coordination Financing and insurance mechanisms a) Employer-based health insurance (private) b) Privately-purchased health insurance (private) c) Government programs (public) -> Medicare--elderly and certain disabled people -> Medicaid--poor (if they meet the eligibility criteria) 2. Technology Driven and Focusing on Acute Care Increased overuse of new technology has negative outcomes 3. High on Cost, Unequal in Access, and Average in Outcome Financing and insurance are the key predictors of access Delivery and payment also influence access (accessibility), but more indirectly Access is determined by four factors: a) Ability to pay (health insurance) b) Availability of services (delivery), e.g., certain rural and remote areas lack
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