Christopher Digiulio MD | Health Insurance Plans

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Health Insurance Plans
Christopher Digiulio MD
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Objectives

• 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
  facilities.
• 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
  medicine

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Hospitals

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

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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.

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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
  conditions.
• Others are specialized
• for specific ages or
• medical conditions.

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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

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Government Agencies

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

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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

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• Health
• Insurance Plans

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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.

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Public / NationalHealth Care Systems

• Mainly funded by taxes and social security
  insurance.
• 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

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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
  stimulated.
• Disadvantage Not every citizen is guaranteed
  health care.
• United States and Switzerland

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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
  expenses.
• Example Canada and the United States

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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.

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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

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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.

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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.

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Managed Care

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

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Health Maintenance Organizations

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

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Preferred Provider Organization

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

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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

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Government Programs

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

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Medicaid

• 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.

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Medicare

• 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.

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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

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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

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Trends in Todays Health Care Systems

• Advances in technology
• Epidemiology
• Bio-ethics
• Socioeconomics
• Complementary (nontraditional) medicine

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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

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The End!