define moral hazard, adverse selection, and cost-shifting

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Question description

Week 7: Health Services Financing

UNIT OBJECTIVES

After completing this unit, you should be able to

  • define moral hazard, adverse selection, and cost-shifting
  • identify the major public programs for the financing of health care
  • compare and contrast Medicare and Medicaid
  • list and describe the four sub-programs of Medicare
  • describe different reimbursement approaches for health services

UNIT LECTURE

When asked how health care services are paid for, many of us think immediately of health insurance. However, we typically don’t think about the dynamics behind health insurance or the various types of programs through which it is delivered. At its most basic level, health insurance is a tool for mitigating risk. An individual purchases health insurance to mitigate the risk of having to pay an enormous medical bill in the event of sickness or injury.

Those who provide health insurance—insurance companies—also work to mitigate risk, albeit from the other side. They attempt to create a risk pool containing a large number of healthy people to offset the expenses accrued by those who do get sick or injured. Premiums, the fees paid for ownership of health insurance, are used to subsidize the cost of the health care provided to those who use the insurance.

Factors that insurance companies need to be mindful of include moral hazard, whereby an insured individual is more prone to seek care than if he or she were paying the medical bill him- or herself; and adverse selection, whereby insurance is mainly purchased by those most in need of it. As with any financial enterprise, if the costs of providing the product or service exceed the revenue, the company goes out of business.

There are several types of insurance programs, both public and private. Together, these programs cover not only individual health services, but public health services, research, and the administration of the delivery and financing of health care in the United States. The majority of public and private expenditures—approximately 81 percent—are directed toward hospital care, provider and clinical services, long-term care, and prescription drug provision (Kovner & Knickman, 2011).

As mentioned in the week 4 lecture, health insurance is a relatively new mechanism for financing health services, and it has grown substantially since the mid-1900s, when only 9 percent of the US population had health insurance (Blumberg & Davidson, 2009). Health insurance can be broken down into private and public insurance.

Private health insurance is primarily employment-based, meaning that individuals receive coverage through commercial health insurance plans for which their employers either pay the premiums or subsidize them, with the employee paying the balance.

Some larger employers choose to self-insure, which means that they administer their own plans and accept the financial risk of doing so. In essence, they act as the insurer of their employees.

Some individuals, either through necessity or choice, opt to purchase their own private insurance coverage through a commercial insurance company or to remain uninsured and accept the risk.

Public health insurance is funded by the government and plays a significant role in the health care system. There are several public programs; two of the most prominent are the Medicare program, created through Title 18 of the Social Security Act of 1935 (SSA), and Medicaid, created through Title 19 of the SSA. Both programs are operated by the Centers for Medicare & Medicaid Services (CMS), a division of the U.S. Department of Health & Human Services (HHS).

Describe the data collection standards used to determine population health concerns in this community, such as disease definition, specified populations, and defined time periods.

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Question description

Communities have different public health issues and concerns that must be addressed. An example of a specific application might include the Rural Healthy People 2010 – Models for Practice, which is a compilation of best practices in addressing rural health concerns, as seen on the Public Health Texas A&M Health Science Center website.

Choose a geographic community and describe ongoing health activities specific to identified health concerns.

Present a 12- to 15-slide Microsoft® PowerPoint® presentation that identifies a local public health issue and how it relates to nationally identified objectives by using the following criteria:

  • Identify sources of data the community uses to assess targeted determinants of health in support of these activities.
  • Describe the data collection standards used to determine population health concerns in this community, such as disease definition, specified populations, and defined time periods.
  • Describe how the data sources could be used to determine the focus of health care in the community–individual or the whole population–including implications for targeted populations.
  • Explain health care determinants that impact population health.

Reference your readings and at least 5 peer-reviewed, scholarly, or similar articles.

Include detailed speaker notes.

Format your presentation according to APA guidelines.

benefits of implementing a new health information technology system to comply with the current mandates

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Question description

You have been asked by your health care organization to provide a detailed report on the benefits of implementing a new health information technology system to comply with the current mandates. Develop a report of 10–12 pages detailing how information technology systems can be used to analyze organizational data for a health care organization. This should include types of systems where data may be retrieved and how IT and various applications can be used to aggregate and analyze the data to understand issues, identify root causes, and document progress related to implemented changes, patient progress, quality assurance, and compliance. Make sure to address the following questions:

  • With plenty of data stored on computer systems, data should not be a problem, but access to the data and sharing of information may have implications under federal regulations. What precautions might you suggest when handling health care data? Be sure to apply current trends in health care from proven sources and models.
  • Consider the support capabilities of a typical health care operation and where employees may access data of various types related to patient needs. What might be accessed, and what controls may be needed to protect patient data?
  • From a departmental perspective, consider the role of the health information manager (HIM). What qualifications and experience would be needed for your specific health care setting? What functions and role would the HIM have in regard to this organization’s medical records?
  • As technology advances, what compliance issues and regulations do health care managers at this organization need to be on top of? Consider the impact of falling behind the technology curve not only in terms of productivity but regulatory compliance. What role do the Affordable Care and Patient Protection Acts have on the implementation and use of technology and electronic health records (EHRs) at this setting?
  • paper must be 11 pages

Discuss the meaning and implications of the statement that “most people who seek medical care are unaffected by the care they receive

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Question description

  2. List the guidelines for evaluating health information.
  3. Discuss the qualities of valid and reliable health information.
  4. Name at least forty sources of reliable health information.
  1. Describe some deceptive terms that are used in the labeling of health products.
  2. Identify 31 signs and symptoms that require when to seek immediate health care.
  3. Identify 14 guidelines you should consider to ensure proper and safe care while in the hospital.
  4. What is your normal body temperature?
  5. Identify 3 guidelines for seeking treatment for a fever.
  6. Discuss the characteristics of selecting the ideal physician.
  7. List and identify various specialties of health care providers on the chart below.

    Select Health Care Specialists

    Specialists Field of Specialist  Specialists  Field of Specialist

1 22.
2 23
3 24
4 25
5 26
6 27
7 28
8 29
9 30
10 31
11 32
12 33
13 34
14 35
15 36
16 37
17 38
18 39
19 40
20 41.
21
  1. Discuss 13 tips to ensure good patient physician communication.
  2. Discuss reasons a patient may want a second opinion.
  3. Identify some good options to help seek a second option.
  4. List 10 do you know your Medical Rights? (Use Bullets or # each)
  5. Describe the components of a physical examination.
  6. Describe the immunization schedule for an adult.
  7. Identify several methods of paying for health care services.
  8. List 16 essentials for your Medicine Cabinet.(#each)
  9. Please list 10 Selected Complementary and Alternative Approaches to Medicine on the chart.

    Selected Complementary and Alternative Approaches to Medicine

    Name /Type  Proposed Therapeutic  How It Works

List Chapter Key-Terms and Definitions (# Each Term)

Essay Items

 

  1.   Describe in detail the requirements of health research if its findings and conclusions are to be trusted.
  2. Discuss the importance of going to a physician while you are in good health and free of any obvious signs or symptoms of disease.
  3. Identify and discuss actions that patients can take to communicate better with their physician.
  4. Doctors use more diagnostic tests than are necessary, often more than are good for us. Do you agree or disagree?  Defend your answer.
  5. Explain the difference between absolute risk and relative risk. Which of these two terms is more likely to be reported in a misleading way? Give an example.
  6. Discuss your reaction to the statement that “health care is the right of everyone, regardless of their ability to pay.”
  7. Describe the kind of attitude that patients should have as they enter the health care market.
  8. Explain the difference between informed consent and implied consent, and give several examples of each.
  9. List guidelines that should be used when consulting with a medical doctor by way of email.
  10. Discuss the principal role and function of the primary-care physician.
  11. Compare and contrast the advantages and disadvantages of prepaid health insurance and fee-for-service health insurance
  12. Identify ways that a college student who attends a college/university away from his or her home can select a primary-care physician and/or medical specialists.
  13. Discuss the meaning and implications of the statement that “most people who seek medical care are unaffected by the care they receive.”
  14. The text states that the internet is like a “wild frontier” with regard to health information. What does this imply? What are some criteria for assessing the quality of information on the internet?

Discuss the three components of the physical examination. What is the rationale for the statement that what a patient tells the doctor is more important than what diagnostic and laboratory tests reveal? What are the implications of this statement? What are the underlying assumptions of this statement.