HCD 303 Final Exam Study Guide
Study online at https://quizlet.com/_76y95z
a set of connected things or parts forming a complex
System
whole
Quality how good or bad something is
Access a person's ability to get care or coverage
Cost cost
Universal Coverage all residents have coverage
the principle that governments have an obligation to en-
Social Solidarity sure that every citizen has access to all social services
including healthcare
the principle belief that matter of government responsi-
Subsidiarity bility should be handled at the lowest level of government
that makes operational sense
the principle belief in giving to something knowing that
General Reciprocity
you may not get an immediate returned benefititifif
Centralized Organized at the federal level
Decentralized Organized at the regional or state level
Public Health Services/Insurance public, government run
private, privately run
Only those who make over ~$70,000/year qualify
Private Health Services/Insurance
The premium is set by your performance on an individual
health assessment
The set dollar amount that you must pay at the point of
Copayment
service
The set percentage of the bill that must be paid at the point
Coinsurance
of service
The amount that must be paid out-of-pocket annually,
Deductible
before insurance coverage kicks in
Sickness Funds
, HCD 303 Final Exam Study Guide
Study online at https://quizlet.com/_76y95z
~130 sickness funds today (although this number is con-
tinually 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
Children under 18 years of age exempt from all cost-shar-
ing
Adults:
Annual cap equal to 2% of household income
Safety Net Annual cap lowered to 1% of household income for qual-
ifying chronically ill people
Unemployed contribute to SHI in proportion to their
unemployment entitlements; For long term unemployed
government contributes on their behalf
Cost Sharing (all USD):
Outpatient Prescriptions: $6.40 - $12.70
Inpatient Stay: $10.00/day (first 28 days/yr)
Cost Sharing 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
, HCD 303 Final Exam Study Guide
Study online at https://quizlet.com/_76y95z
it is the function of a system concerned with the mobiliza-
tion, accumulation, and allocation of money to cover the
Health Financing
health needs of the people, individually and collectively,
in the health system
The percent of money spent on healthcare every year, in
Health Spending as % of GDP relation to the total amount spent throughout all indus-
tries in the same year
A payment model where all healthcare services, products,
and prescription medications are unbundled and paid for
separately.
Fee-for-service (FFS)
incentive: Overtreatment, Provide more services, testing,
and treatments that are billable through an ICD-code.
payment model that reimburses organizations and/or
Per Diem providers based upon the number of days treatment was
given
A payment model that reimburses healthcare organiza-
tions and physicians who achieve, improve, or exceed their
performance on specified quality and cost measures, as
Pay-for-performance well as other benchmarks.
incentive: Measure of performance metrics, Incentives can
be financial or non-financial, Adherence to process
Physicians are paid a predetermined salary based upon
their level of expertise and experience.
Salary
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, Reference Pricing)
, HCD 303 Final Exam Study Guide
Study online at https://quizlet.com/_76y95z
DRG - A prospective payment model in which hospitals
are reimbursed with a fixed fee regardless of the actu-
al costs. Includes hospital expenses only. ACA required
30-day readmission penalty
DRG Incentive - Reduce length of stay, Discharge appro-
priately, 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 hospital-
ization).
The EDRG acts as a forcing function - encouraging physi-
cian 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
A prospective payment model where the hospital
or provider is paid a contracted rate per-mem-
ber-per-month, regardless of the number of services pro-
vided.
Capitation
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 hospi-
Study online at https://quizlet.com/_76y95z
a set of connected things or parts forming a complex
System
whole
Quality how good or bad something is
Access a person's ability to get care or coverage
Cost cost
Universal Coverage all residents have coverage
the principle that governments have an obligation to en-
Social Solidarity sure that every citizen has access to all social services
including healthcare
the principle belief that matter of government responsi-
Subsidiarity bility should be handled at the lowest level of government
that makes operational sense
the principle belief in giving to something knowing that
General Reciprocity
you may not get an immediate returned benefititifif
Centralized Organized at the federal level
Decentralized Organized at the regional or state level
Public Health Services/Insurance public, government run
private, privately run
Only those who make over ~$70,000/year qualify
Private Health Services/Insurance
The premium is set by your performance on an individual
health assessment
The set dollar amount that you must pay at the point of
Copayment
service
The set percentage of the bill that must be paid at the point
Coinsurance
of service
The amount that must be paid out-of-pocket annually,
Deductible
before insurance coverage kicks in
Sickness Funds
, HCD 303 Final Exam Study Guide
Study online at https://quizlet.com/_76y95z
~130 sickness funds today (although this number is con-
tinually 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
Children under 18 years of age exempt from all cost-shar-
ing
Adults:
Annual cap equal to 2% of household income
Safety Net Annual cap lowered to 1% of household income for qual-
ifying chronically ill people
Unemployed contribute to SHI in proportion to their
unemployment entitlements; For long term unemployed
government contributes on their behalf
Cost Sharing (all USD):
Outpatient Prescriptions: $6.40 - $12.70
Inpatient Stay: $10.00/day (first 28 days/yr)
Cost Sharing 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
, HCD 303 Final Exam Study Guide
Study online at https://quizlet.com/_76y95z
it is the function of a system concerned with the mobiliza-
tion, accumulation, and allocation of money to cover the
Health Financing
health needs of the people, individually and collectively,
in the health system
The percent of money spent on healthcare every year, in
Health Spending as % of GDP relation to the total amount spent throughout all indus-
tries in the same year
A payment model where all healthcare services, products,
and prescription medications are unbundled and paid for
separately.
Fee-for-service (FFS)
incentive: Overtreatment, Provide more services, testing,
and treatments that are billable through an ICD-code.
payment model that reimburses organizations and/or
Per Diem providers based upon the number of days treatment was
given
A payment model that reimburses healthcare organiza-
tions and physicians who achieve, improve, or exceed their
performance on specified quality and cost measures, as
Pay-for-performance well as other benchmarks.
incentive: Measure of performance metrics, Incentives can
be financial or non-financial, Adherence to process
Physicians are paid a predetermined salary based upon
their level of expertise and experience.
Salary
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, Reference Pricing)
, HCD 303 Final Exam Study Guide
Study online at https://quizlet.com/_76y95z
DRG - A prospective payment model in which hospitals
are reimbursed with a fixed fee regardless of the actu-
al costs. Includes hospital expenses only. ACA required
30-day readmission penalty
DRG Incentive - Reduce length of stay, Discharge appro-
priately, 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 hospital-
ization).
The EDRG acts as a forcing function - encouraging physi-
cian 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
A prospective payment model where the hospital
or provider is paid a contracted rate per-mem-
ber-per-month, regardless of the number of services pro-
vided.
Capitation
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 hospi-
