Christopher Digiulio MD | Health Insurance Plans - PowerPoint PPT Presentation

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Christopher Digiulio MD | Health Insurance Plans


Christopher Digiulio MD is a professional Family Physician in Bend, Oregon. – PowerPoint PPT presentation

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Title: Christopher Digiulio MD | Health Insurance Plans

Health Insurance Plans
Christopher Digiulio MD
  • Students will be able to
  • Differentiate between private, public, and
    non-profit facilities.
  • Predict where and how factors such as cost,
    managed care, technology, and aging population,
    access to care, alternative therapies, and
    lifestyle behavior may affect various health
    delivery system models.
  • Research the organizational structures and
    services of various types of health care
  • Differentiate between various types of health
    care insurance plans
  • Analyze the cause and effect on health care
    system change based on the influence of
    technology epidemiology, bio-ethics,
    socioeconomic and various forms of complimentary

  • Vary according to
  • Size
  • Small
  • Large
  • Ownership
  • Proprietary / private / for profit
  • Nonprofit
  • Government
  • Religious
  • Services
  • General
  • Specialty

Long-Term Care Facilities
  • Provide long-term care for elderly patients and
    for patients in rehabilitation.
  • Levels of long-term care
  • A nursing home provides care for patients who can
    no longer care for themselves.
  • An independent living facility
  • allows patients to use only
  • the services they need, such
  • as transportation or
  • housekeeping.

Medical Offices
  • May be operated by one or two doctors or a large
    groups of health care professionals.
  • Some medical offices treat a wide range of
  • Others are specialized
  • for specific ages or
  • medical conditions.

Other Types of Facilities
  • Dental offices
  • Clinics
  • Optical centers
  • Emergency Care Centers
  • Laboratories
  • Home Health Care
  • Hospice
  • Mental Health
  • Genetic Counseling Centers
  • Rehabilitation
  • Health Maintenance Organizations (HMOs)
  • Industrial Care Centers
  • School Health Services

Government Agencies
  • World Health Organization (WHO)
  • U.S. Department of Health and Human Services
  • National Institute of Health (NIH)
  • Centers for Disease Control and Prevention (CDC)
  • Food and Drug Administration (FDA)
  • Agency for Health Care Policy And Research
  • Occupational Health and Safety Administration
  • State and local health departments

Volunteer and Nonprofit Agencies
  • American Cancer Society
  • American Heart Association
  • American Red Cross
  • National Association of Mental Health
  • National Foundation of the March of Dimes

  • Health
  • Insurance Plans

Health Care Systems
  • Nearly every industrialized country has a
    national health care system.
  • Some countries have public or national health
    care systems, and other countries have private
    health care systems.

Public / NationalHealth Care Systems
  • Mainly funded by taxes and social security
  • Advantage Every citizen is guaranteed health
    care regardless of economic status.
  • Disadvantages Health care is not always
    comprehensive, and taxes may be higher.
  • Norway, France, the United Kingdom, and Canada

Private Health Care Systems
  • Mainly funded by private insurance agencies and
    out-of-pocket payments.
  • Advantages Coverage is often comprehensive,
    taxes may be lower, and economic growth is
  • Disadvantage Not every citizen is guaranteed
    health care.
  • United States and Switzerland

Mixed Systems
  • Very few countries have a purely public or
    private system
  • Most countries create a mixed system by using
    various funding sources to cover health care
  • Example Canada and the United States

Health Insurance
  • The rising cost of health care is good for the
    economy, but the expenses are a burden for most
    individuals and families.
  • In the 1920s, the United States developed a
    system of health insurance to help cover the cost
    of medical expenses.

Health Insurance Terms
  • Premium the amount paid to an insurance agency
    for a health insurance policy
  • Deductible - the amount that must be paid by the
    patient before the insurance agency will begin to
    make payments
  • Co-payment - an amount paid by the patient for a
    certain service
  • Out-of-pocket - a medical bill that must be paid
    by the patient

Individual and Group Insurance
  • Individual insurance is when a person purchases a
    policy and agrees to pay the entire premium for
    health coverage.
  • Group insurance is generally purchased through an
    employer. The premium is split between the
    employer and the person being insured.

Managed Care
  • Two primary concepts of managed care
  • To promote good health
  • To practice preventive medicine
  • Managed care plans offer medical services through
    a system of health care providers. The system of
    providers offers services at reduced rates.

Managed Care
  • Health Maintenance Organizations
  • Preferred Provider Organizations
  • Point of Service

Health Maintenance Organizations
  • Clients must pay a premium, deductible, and
  • Clients must visit in-network doctors and select
    a primary care physician.
  • HMOs urge clients to practice healthy living and
    to receive preventive treatments.

Preferred Provider Organization
  • Clients must pay a premium, deductible, and
  • Clients do not have to choose a primary care
  • Clients may visit non-network physicians, but
    coverage is greater with in-network physicians.
  • PPOs often have other fees and co-payments.

Point of Service
  • Clients must pay a premium.
  • Clients must chose a primary care physician.
  • For in-network physicians, there is usually no
    deductible and co-payments are low.
  • Specialists may be non-network physicians, but
    coverage may be limited

Government Programs
  • In the 20th century, the United States government
    began to realize the need for public medical
  • In 1965, President Lyndon B. Johnson instituted
    two medical assistance programs to help those
    without health insurance.
  • Medicaid
  • Medicare

  • Income or needs based program
  • Designed by the federal government, but
    administered by state governments
  • Usually includes individuals with low incomes,
    children who qualify for public assistance, and
    individuals who are blind or physically disabled.

  • Program for any citizen age 65 or older
  • Administered by the federal government
  • After an individual pays a deductible, Medicare
    will cover 80 of all medical expenses.

Medicare Services
  • Part A Hospital Care
  • Hospitalization
  • Skilled nursing facilities
  • Home health care
  • Hospice care
  • Long-term care facilities
  • Part B Outpatient Services
  • Medical expenses, including therapy, medical
    equipment, and testing
  • Preventive Care

Workers Compensation
  • Provides treatment for workers injured on the job
  • Administered by the state
  • Reimburses the worker for wages lost because of
    on-the-job injury

Trends in Todays Health Care Systems
  • Advances in technology
  • Epidemiology
  • Bio-ethics
  • Socioeconomics
  • Complementary (nontraditional) medicine

Organizational Structure
  • An tool designed to help a facility operate
    smoothly by outlining responsibilities
  • It describes the line of
  • authority that
  • establishes levels
  • of responsibility
  • and supervision

The End!
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