Healthcare Ecosystems D391
Which health plan is regulated under the Employee Retirement Income Security Act (ERISA)? - ANSWER: Self-
Insured
Medicare has four parts, A, B, C, and D: - ANSWER: Medicare Part A is hospital coverage. Part B is Medicare's
principal benefit covering physician and other outpatient-provider services. 1997, significant changes came to
Medicare, creating Medicare Part C. The government worked with private Health Maintenance Organizations
(HMOs) to participate in Part C, called Medicare Advantage (MA). This is where Parts A and B are covered in an
HMO care delivery model. 2003, Medicare Part D evolved under the Medicare Prescription Drug,
Improvement, and Modernization Act (MMA).
TRICARE - ANSWER: military health plan that provides services for active duty personnel and their families,
survivors of military personnel and retired military personnel and their families
The Federal Trade Commission (FTC) - ANSWER: Has a role in MA plans. Because MA is a competitive
consumer benefit, the FTC is responsible for enforcing antitrust laws.
Nixon administration HMO act of 1973 - ANSWER: health maintenance organization= affordable and accessible
FOUR PAYER MODELS: - ANSWER: Beveridge, Bismarck, National Health Insurance, and the Out-of-pocket
model. The US is a Bis/Bev model.
Fee for service model - ANSWER: Reimbursement for providers was based on the number of services in a visit.
Expensive.
Health maintenance organizations - ANSWER: Limited coverage but controlled costs. Paid capitation payment
and restricts patients to a preferred list of providers.
ACA Affordable Care Act of 2010 replaced the FFS model. - ANSWER: Medicare and Medicaid managed
organizations (MCOs) are mandated by the ACA. They had to transition to value-based care. VBC model and
capitated fees. Many MCO's transitioned their business to VBC models
, VBC- Value based care. Quality over quantity - ANSWER: An improvement to provider performance.
Healthcare aligns with patient outcomes. Govt. Regulates healthcare customer service, skills, and compliance
processes. Focus on wellness and prevention.
Moral Hazard - ANSWER: Consumers buy unnecessary additional healthcare because they do not receive the
full benefit. Individuals incur no consequence for a decision, allowing for extravagant choices.
Adverse Selection - ANSWER: Consumers do not purchase health insurance until they need coverage. The
insured has information that the insurer does not. Cost below the true risk level.
5 Main funding models of the U.S. Healthcare system - ANSWER: The National Health Insurance Model (single-
payer model), Bismarck Model (a combination of payers), Beveridge, Bev/Bis hybrid, Self-Funded.
Bismarck - ANSWER: A social health insurance model.
Healthcare system - ANSWER: An organization of individuals and resources that deliver services to clients
Insurance regulations - ANSWER: Ensure the consumer is protected from harm and make healthcare accessible
and affordable.
5 P's of Healthcare eco system - ANSWER: Patients, Providers, professional administrators, policymakers,
payers
Fundamental components of a healthcare system - ANSWER: Organization, funding, and delivery
What do healthcare services include? - ANSWER: Emergency, preventative, rehabilitative, long-term, hospital,
diagnostic, primary, palliative, home care.
Why is cultural competence important? - ANSWER: Client's values and preferences will be respected
Component of the quadruple aim of healthcare - ANSWER: Improve the overall health of a given population.
Clinical social workers - ANSWER: Provides assessments, diagnose, and counseling
Which health plan is regulated under the Employee Retirement Income Security Act (ERISA)? - ANSWER: Self-
Insured
Medicare has four parts, A, B, C, and D: - ANSWER: Medicare Part A is hospital coverage. Part B is Medicare's
principal benefit covering physician and other outpatient-provider services. 1997, significant changes came to
Medicare, creating Medicare Part C. The government worked with private Health Maintenance Organizations
(HMOs) to participate in Part C, called Medicare Advantage (MA). This is where Parts A and B are covered in an
HMO care delivery model. 2003, Medicare Part D evolved under the Medicare Prescription Drug,
Improvement, and Modernization Act (MMA).
TRICARE - ANSWER: military health plan that provides services for active duty personnel and their families,
survivors of military personnel and retired military personnel and their families
The Federal Trade Commission (FTC) - ANSWER: Has a role in MA plans. Because MA is a competitive
consumer benefit, the FTC is responsible for enforcing antitrust laws.
Nixon administration HMO act of 1973 - ANSWER: health maintenance organization= affordable and accessible
FOUR PAYER MODELS: - ANSWER: Beveridge, Bismarck, National Health Insurance, and the Out-of-pocket
model. The US is a Bis/Bev model.
Fee for service model - ANSWER: Reimbursement for providers was based on the number of services in a visit.
Expensive.
Health maintenance organizations - ANSWER: Limited coverage but controlled costs. Paid capitation payment
and restricts patients to a preferred list of providers.
ACA Affordable Care Act of 2010 replaced the FFS model. - ANSWER: Medicare and Medicaid managed
organizations (MCOs) are mandated by the ACA. They had to transition to value-based care. VBC model and
capitated fees. Many MCO's transitioned their business to VBC models
, VBC- Value based care. Quality over quantity - ANSWER: An improvement to provider performance.
Healthcare aligns with patient outcomes. Govt. Regulates healthcare customer service, skills, and compliance
processes. Focus on wellness and prevention.
Moral Hazard - ANSWER: Consumers buy unnecessary additional healthcare because they do not receive the
full benefit. Individuals incur no consequence for a decision, allowing for extravagant choices.
Adverse Selection - ANSWER: Consumers do not purchase health insurance until they need coverage. The
insured has information that the insurer does not. Cost below the true risk level.
5 Main funding models of the U.S. Healthcare system - ANSWER: The National Health Insurance Model (single-
payer model), Bismarck Model (a combination of payers), Beveridge, Bev/Bis hybrid, Self-Funded.
Bismarck - ANSWER: A social health insurance model.
Healthcare system - ANSWER: An organization of individuals and resources that deliver services to clients
Insurance regulations - ANSWER: Ensure the consumer is protected from harm and make healthcare accessible
and affordable.
5 P's of Healthcare eco system - ANSWER: Patients, Providers, professional administrators, policymakers,
payers
Fundamental components of a healthcare system - ANSWER: Organization, funding, and delivery
What do healthcare services include? - ANSWER: Emergency, preventative, rehabilitative, long-term, hospital,
diagnostic, primary, palliative, home care.
Why is cultural competence important? - ANSWER: Client's values and preferences will be respected
Component of the quadruple aim of healthcare - ANSWER: Improve the overall health of a given population.
Clinical social workers - ANSWER: Provides assessments, diagnose, and counseling
