HPAM3600E Final Exam
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1. social determinants of health: social conditions into which people are born and that affect their daily
lives and overall well-being as they move through life
2. Law as a Social Determinant of Health (Part 1): The law can be used to design and perpetuate
social conditions that can have terrible physical, mental, and emotional effects on individuals and populations
- Ex: Separate by equal doctrine
3. Law as a Social Determinant of Health (Part 2): The law can be utilized as a mechanism
through which behaviors and prejudices are transformed into distributions of well-being among populations
- Ex: Health care discrimination and bias based on race, gender, age, class, etc
4. Law as a Social Determinant of Health (Part 3): Laws can be determinative of health through
under-enforcement
- Ex: Housing regulations are of little value to health without the will or sources to enforce them (mold, poor air quality,
etc)
5. Law as a Social Determinant of Health (part 4): The law can be used to structure direct
responses to health-harming social needs that result from things like impoverishment, illness, market failure, and
individual behavior that harms others
-Ex: Emergency Medical Treatment in Active Labor Act or state police powers
6. beneficiary: Consumer; the individual who is covered by the plan
7. Premium: Annual fee paid by the beneficiary to the health plan, usually in monthly installments, to secure health
insurance coverage
8. Deductible: Amount of money a beneficiary must pay out-of-pocket before the insurance company assists with
paying for services
9. Cost-sharing (co-payment, or co-insurance): an amount the beneficiary pays per service after
the deductible is met
- beneficiary normally pays 10-20%
10. fee-for-service: a system under which doctors and hospitals receive a payment for each service they provide
- payed for volume and quantity of services provided, regardless of outcome
11. Capitation: System of payment used by managed care plans in which physicians and hospitals are paid a
fixed, per capita amount for each patient enrolled over a stated period regardless of the type and number of services
, HPAM3600E Final Exam
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provided; reimbursement to the hospital on a per-member/per-month basis to cover costs for the members of the
plan.
12. discounted fees: Pre-negotiated fees per service
- modified form of fee-for-service
- provider can bill insurer for each specific service (fee schedule)
13. Pros of capitation: -provides fixed payments to providers and dissuades providers from unnecessary
services
- promotes efficiency and cost control
- reduces bookkeeping overhead
- Allows providers to focus on face-to-face services and preventative care
14. Cons of capitation: - may cause providers to use cheaper drugs/services
- encourages providing fewer services
- high population areas means low capitation rates
- can lead to long wait times and short visits
15. Government programs (public): Financed by federal or state governments
medicare, medicaid
16. Privately purchased health insurance: individuals pay for it
17. Employer-based health insurance (private): offered to employees and dependents as a
benefit of employment
- nearly half of the pop. of the U.S. has this type of insurance
- offered by large companies (200 or more employees)
18. Why do people choose to be insured?: uncertainty and risk
- There is uncertainty whether an expensive and unforeseen event that impacts their health status will occur
- There is risk of financial exposure due to the unexpected event
19. Adverse Selection: uncertainty + risk + asymmetric information
- unhealthy people over-select a particular plan, making the plan more expensive
20. asymmetric information: a situation in which one party to an economic transaction has less information
than the other party
- health insurance companies want healthy individuals to buy more coverage
, HPAM3600E Final Exam
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21. High Deductible Health Plan: A health plan that combines a savings option with a health insurance
plan carrying a high deductible
- Monthly premium is lower (younger and healthier people prefer this plan)
- Employers prefer this plan
- Ex. Health Savings Account (HSA)
22. Why do insurance companies set premiums?: To cover most of their expenses
23. Experience Rating (medical underwriting: the process by which a health insurer uses medica
history to determine if they can offer them a policy and whether the policy will offer pre-existing condition exclusions
and/or a premium that is higher than the standard premium
- Based on health status and claims in prior year(s)
- Won't give policy to someone who poses a greater risk to the insurer (older, unhealthier people)
- Medical underwriting was prohibited in 2014 by the ACA
24. (Pure) Community rating: health insurance premiums are charged based on people in a given group
or area
- Based on factors unrelated to previous use of medical care, such as geography
- All persons in the community rating system pay the same amount
25. Modified Community rating: demographic characteristics such as age and gender are taken into
consideration
- Still allow for some variations in premiums (e.g., Age and gender), although premiums cannot vary based on a person
or group's medical history
- much more common than pure community rating
26. Which type of rating is the most suitable from a policy stand point?: There is no
right answer; depends on whether you are considering equity and efficiency
27. Insurance Coverage Overview: The United States does not have a single national health insurance
program that covers the entire population
28. What percentage of the U.S. is uninsured?: 8.8%
29. Where do most individuals obtain insurance coverage?: Through their employer
30. What are two examples of governmental health insurance?: Medicare and medicaid
Study online at https://quizlet.com/_hjuni8
1. social determinants of health: social conditions into which people are born and that affect their daily
lives and overall well-being as they move through life
2. Law as a Social Determinant of Health (Part 1): The law can be used to design and perpetuate
social conditions that can have terrible physical, mental, and emotional effects on individuals and populations
- Ex: Separate by equal doctrine
3. Law as a Social Determinant of Health (Part 2): The law can be utilized as a mechanism
through which behaviors and prejudices are transformed into distributions of well-being among populations
- Ex: Health care discrimination and bias based on race, gender, age, class, etc
4. Law as a Social Determinant of Health (Part 3): Laws can be determinative of health through
under-enforcement
- Ex: Housing regulations are of little value to health without the will or sources to enforce them (mold, poor air quality,
etc)
5. Law as a Social Determinant of Health (part 4): The law can be used to structure direct
responses to health-harming social needs that result from things like impoverishment, illness, market failure, and
individual behavior that harms others
-Ex: Emergency Medical Treatment in Active Labor Act or state police powers
6. beneficiary: Consumer; the individual who is covered by the plan
7. Premium: Annual fee paid by the beneficiary to the health plan, usually in monthly installments, to secure health
insurance coverage
8. Deductible: Amount of money a beneficiary must pay out-of-pocket before the insurance company assists with
paying for services
9. Cost-sharing (co-payment, or co-insurance): an amount the beneficiary pays per service after
the deductible is met
- beneficiary normally pays 10-20%
10. fee-for-service: a system under which doctors and hospitals receive a payment for each service they provide
- payed for volume and quantity of services provided, regardless of outcome
11. Capitation: System of payment used by managed care plans in which physicians and hospitals are paid a
fixed, per capita amount for each patient enrolled over a stated period regardless of the type and number of services
, HPAM3600E Final Exam
Study online at https://quizlet.com/_hjuni8
provided; reimbursement to the hospital on a per-member/per-month basis to cover costs for the members of the
plan.
12. discounted fees: Pre-negotiated fees per service
- modified form of fee-for-service
- provider can bill insurer for each specific service (fee schedule)
13. Pros of capitation: -provides fixed payments to providers and dissuades providers from unnecessary
services
- promotes efficiency and cost control
- reduces bookkeeping overhead
- Allows providers to focus on face-to-face services and preventative care
14. Cons of capitation: - may cause providers to use cheaper drugs/services
- encourages providing fewer services
- high population areas means low capitation rates
- can lead to long wait times and short visits
15. Government programs (public): Financed by federal or state governments
medicare, medicaid
16. Privately purchased health insurance: individuals pay for it
17. Employer-based health insurance (private): offered to employees and dependents as a
benefit of employment
- nearly half of the pop. of the U.S. has this type of insurance
- offered by large companies (200 or more employees)
18. Why do people choose to be insured?: uncertainty and risk
- There is uncertainty whether an expensive and unforeseen event that impacts their health status will occur
- There is risk of financial exposure due to the unexpected event
19. Adverse Selection: uncertainty + risk + asymmetric information
- unhealthy people over-select a particular plan, making the plan more expensive
20. asymmetric information: a situation in which one party to an economic transaction has less information
than the other party
- health insurance companies want healthy individuals to buy more coverage
, HPAM3600E Final Exam
Study online at https://quizlet.com/_hjuni8
21. High Deductible Health Plan: A health plan that combines a savings option with a health insurance
plan carrying a high deductible
- Monthly premium is lower (younger and healthier people prefer this plan)
- Employers prefer this plan
- Ex. Health Savings Account (HSA)
22. Why do insurance companies set premiums?: To cover most of their expenses
23. Experience Rating (medical underwriting: the process by which a health insurer uses medica
history to determine if they can offer them a policy and whether the policy will offer pre-existing condition exclusions
and/or a premium that is higher than the standard premium
- Based on health status and claims in prior year(s)
- Won't give policy to someone who poses a greater risk to the insurer (older, unhealthier people)
- Medical underwriting was prohibited in 2014 by the ACA
24. (Pure) Community rating: health insurance premiums are charged based on people in a given group
or area
- Based on factors unrelated to previous use of medical care, such as geography
- All persons in the community rating system pay the same amount
25. Modified Community rating: demographic characteristics such as age and gender are taken into
consideration
- Still allow for some variations in premiums (e.g., Age and gender), although premiums cannot vary based on a person
or group's medical history
- much more common than pure community rating
26. Which type of rating is the most suitable from a policy stand point?: There is no
right answer; depends on whether you are considering equity and efficiency
27. Insurance Coverage Overview: The United States does not have a single national health insurance
program that covers the entire population
28. What percentage of the U.S. is uninsured?: 8.8%
29. Where do most individuals obtain insurance coverage?: Through their employer
30. What are two examples of governmental health insurance?: Medicare and medicaid
