Study Guide

HSM 541-Final Exam

The difference between PPO & HMO Insurance
HMO Plan
An HMO provides access to certain doctors and hospitals within its network.

Youre must select a primary care physician (PCP), who will decide what treatment you need.

PCP referral is required to be covered when you see a specialist or have a special test done.

If you decide to see a doctor outside of an HMO network you will be responsible for the entire
bill because PPO will not cover it.

Premiums are usually lower for HMO plans, and there is typically no deductible or a low one.

PPO Plan
PPO plans offer more flexibility when picking a doctor or hospital.
You can choose a doctor of your choice without having to see a PCP first. .

You can see a doctor or go to a hospital outside the network and you may be covered. Benefits
are better if you choose to stay in the PPO Network..

Premiums are sometime a little higher, and its common for there to be a deductible.

Similarities between PPO & HMO Insurance

Both HMOs and PPOs retain a network of doctors, hospitals, medical labs, and independent
physicians' groups to deliver and finance health care for members.

Both try to reduce costs by applying specialized management techniques to limit what they
concern as unnecessary or unsuitable medical procedures.

Both also share the goal of dropping health-care costs by meeting on preventive care and general
health promotion.
Retrieved from: https://www.medmutual.com/For-Individuals-and-Families/Health-InsuranceEducation/Health-Insurance-Basics/Types-of-Insurance-Plans.aspx

General Ideas and Concepts: You should be able to understand and apply the following concepts.
Health promotion versus curative approach
Health promotion is the same as preventative health care. In a preventative care, model involves
preventing illness rather than curing it. Individuals are encouraged to live a healthy lifestyle such as
eating right, going to the gym. Preventative measures and tests supported by providers, such as annual
physical exams, mammograms, cholesterol evaluations, and weight loss interventions. The preventative
model expands necessary resources to maintain the best health of individuals or populations rather than
merely curing illness. The costs related to a preventative approach are less than those of a curative
approach.

The final goal is health promotion, which leads to lower health care costs for the employers health plan.
A third method of promoting health is to provide an annual bonus if employees receive specific health
screenings. These selections may include physical exams, mammograms, cholesterol testing, and blood
sugar tests. All of these health screenings promote early documentation of certain conditions, which may
lead to early intervention. In general, the earlier a medical condition is identified and treated, the less
costly it is to cure or control.

The term curative approach refers to a system of care that based on treating illness or alleviating
symptoms. When you get sick and not able to work, thats a good time to schedule an appointment. In
most cases, the physician provides us with a prescription for medication and a list of recommendations
for us to follow. Hopefully, we comply with the doctors orders and feel better in a few days. In this
scenario, curing or alleviating the symptoms or illness is the primary focus of the healthcare provider.
There is little consideration enthusiastic to educating us on how to prevent disease or how to maintain
our health.
Answers in Back of Book
Continuum of care in health services sector:
Primary - Basic or general care, traditionally provided by family practice, pediatric, and internal
medicine providers
Secondary care Specialist-referred care for conditions of a relatively low level of complication
and risk. May be provided in an office or hospital and may be diagnostic or therapeutic.
Tertiary care Highly specialized care administered to patients who have complicated medical
conditions or require high-risk pharmaceutical treatments or surgery by specialists and
subspecialists in a setting that houses high-technology and intensive care services.
Palliative care Care provided at the end of life, regardless of the patient's age, to ease pain and
suffering.
Long Term Care, etc. Provides services that address the health, social, and personal care needs
of individuals who have never developed or have lost the capacity for self-care on a permanent
or intermittent basis.

Role and features of the private and public health sector:

Medicare - A national program that provides health insurance protection to people aged 65 or
over, people entitled to Social Security disability payments for two years or more, and people
with end-stage renal disease regardless of income. It consists of two separate but coordinated
programs: hospital insurance (Part A), which is available to all beneficiaries and supplementary
medical insurance (Part B), which is optional coverage that Medicare beneficiaries may purchase
Medicaid - A joint federal/state entitlement program that pays for medical care on behalf of
certain groups of low-income persons. Enacted in 1965 under Title XIX of the Social Security Act.
Fee for Service - The health services payment system in which physicians and other providers bill
for each unit of service they provide

Managed care - The health services payment system in which physicians and other providers bill
for each unit of service they provide
HMOs - An organization that delivers and manages health services under a risk-based
arrangement. HMOs usually receive a monthly premium or capitation payment for each enrollee
that is based on a projection of what services for a typical patient will cost.
Factors affecting access, costs, and quality of healthcare services
The U.S. healthcare system can be conceptualized by using the triad of care model. This model
includes three dimensions-access, cost, and quality. Can you think of two factors in our
healthcare system which may impact each of these dimensions?
The U.S. healthcare system can be conceptualized by using the triad of care model. This model
includes three dimensions-access, cost, and quality. Can you think of two factors in our
healthcare system which may impact each of these dimensions?
Access is impacted by--- family income, geographic location, availability of transportation,
insurance coverage, individual perceptions of health issues, convenience of medical services, lack
of physicians, etc. Cost is impacted by--- geographic location (urban vs. rural), level of care
(hospital vs. outpatient), technology, insurance benefits, nonprofit vs. for profit status of facility,
etc. Quality is impacted by: reputation of facility, credentials and licensure of the staff, Joint
Commission accreditation status, awards received by organization (Top 100 Heart Hospital in
U.S.), physicians who admit to the hospital, etc.

Characteristics of special populations which receive specialized health services

Reasons for the uninsured and demographics in the U.S.

Problems/issues with managed care implementation in the U.S.

The role of Medicare and Medicaid

Medicare is a federally funded program; Medicaid is funded by state and federal government
Medicare is administered at the federal level, Medicaid is administered at state
Medicare provides coverage to Americans 65 and over and those who are disabled; Medicaid
provides coverage to individuals and families of all ages.
Medicare is available to everyone 65 years and older regardless of income; Medicaid is available
only to those who fall below income guidelines.
Medicare benefits are standardized and divided into 4 categories (Parts A-D), Medicaid benefits
are determined by each state.

Medicare provides limited long term care reimbursement, Medicaid funds significant portion of
long term care.

Impact of competition in the U.S. healthcare marketplace

General insurance concepts:
Risk assessment - Evaluating the risk that certain behaviors or personal choices may have on
health status. Also used to describe the evaluation of risk to the provider or an insurer inherent
in the provision of health services to a defined population
Risk pooling - Spreading the risk of an adverse event such as an organ transplantation over a
large group so that one or more such catastrophic events may be offset by limited or no use of
services on the part of the majority of those insured.
Payment methodologies
HIPAA, EMTALA, and COBRA legislation and implementation

COBRA: Legislation passed to ensure the continuation of insurance benefits for

individuals who lose their jobs.
EMTALA: Legislation passed to ensure that all individuals receive emergency care
regardless of their ability to pay. A statute governing the treatment required for
persons seeking care from an emergency department to ensure against
dumping of uninsured patients.
HIPAA: Legislation passed to standardize code sets for electronic transactions
and to provide standards for the security and privacy of health data.
National legislation enacted to correct some of the gaps in the health insurance
industryprincipally, the gap in insurance coverage when employees changed
employers and had to 491492experience a waiting period before their new
coverage became effective. HIPAA was also enacted to address some of the
limitations of small-business coverage. Its amendments address the need for
confidentiality of patient and provider data in research and other activities.
Hospitals: factors which impact hospital operations and viability (revenues, costs, etc.)
Dealing with workforce supply issues for medical professions
Recruitment and retention strategies to overcome workforce supply
Components/services of employer sponsored health plans
Preventative services of employer sponsored health plans

Quality improvement management systems

Quality indicators and processes to measure quality care
Strategies for medical error prevention
Fraud and abuse issuesViolations
Penalties,
Enforcement
What are the advantages of having a provider network? What are the disadvantages?
Provider Network is collected of physicians, hospitals and other providers that offer health care services
to members of that health insurance plan. Before a plan like this existed people were able to go to any
doctor they wanted. But todays insurance plans like HMO, PPO and POS plans have a list of doctors and
facilities to choose from.
To stay inexpensive, health insurance plans must have an equally varied list of providers and hospitals
within their networks. The same is true for doctors and hospitals, which often rely on inclusion in major
plans in order to save their doors open. To become part of a network, a provider must have a contract
with the health insurance company. This agreement typically gives the doctors and other providers a
steady stream of patients and bargains the health insurance companies service at reduced rates. One of
the advantages of this plan it helps keep the rates down but the downside is it forces limitations on your
choice to select your own medical providers.
Retrieved from: http://health.howstuffworks.com/health-insurance/provider-network.htm