D391- Healthcare Ecosystems (Part
1+2)
Bismarck Model - ANSWER: Payer is insurance-style, not-for-profit 'sick fund'; Government regulates closely
and reimburses for social needs in the plan of care.
Beveridge Model - ANSWER: Government is the payer and controls healthcare costs.
National Health Insurance Model - ANSWER: Government is the payer; Providers are private; A single-payer
model.
Out-of-Pocket Model - ANSWER: Patients pay directly for care; Also called 'self-funding'; Includes deductibles,
premiums, and co-insurance costs.
Fee-for-Service (FFS) - ANSWER: Providers receive payment for services performed.
Health Maintenance Organizations (HMO) - ANSWER: HMO providers were paid capitation payments,
restricting patients to a preferred list of providers and controlling access to care.
Health Insurance - ANSWER: Helps protect individuals from bearing the full expense of medical treatments;
offers wellness and prevention programs.
Health Insurance Inequalities - ANSWER: A significant challenge in the United States; many cannot achieve
accessible and equitable healthcare.
Risk in Healthcare Insurance - ANSWER: One of the biggest challenges; yearly health plans use actuaries to
determine premium payments.
Actuaries - ANSWER: Combine extensive data from several sources to predict the plan's cost for the coming
year.
, Premium - ANSWER: The amount you pay monthly to maintain your insurance.
Deductible - ANSWER: The amount of money you have to pay before the insurance company will share the
cost.
Copays - ANSWER: Paid by patients as part of their insurance expenses.
Insurance Risk - ANSWER: An event covered by insurance; the risk of payment is borne by the insurer.
Insurance Expenses - ANSWER: Payments such as deductibles, premiums, and copays.
Moral Hazard - ANSWER: When a consumer buys additional, unnecessary healthcare because they do not
receive the full benefit.
Adverse Selection - ANSWER: Where a consumer does not purchase health insurance until they need
coverage.
Value-based Care (VBC) - ANSWER: Provider of service awards for quality patient care.
Wellness and Prevention - ANSWER: Reduce cost and improve patient outcomes.
Healthcare Providers - ANSWER: Must transition to value-based care to reduce costs and deliver quality care.
Legislation - ANSWER: Encircled by federal, state, and local policies to keep people safe and improve
healthcare delivery.
Patient population delivery - ANSWER: Covers operations and optimization of patient privacy information.
Anti-kickback - ANSWER: When a physician receives financial incentives for referrals or drives a patient to a
specific product.
1+2)
Bismarck Model - ANSWER: Payer is insurance-style, not-for-profit 'sick fund'; Government regulates closely
and reimburses for social needs in the plan of care.
Beveridge Model - ANSWER: Government is the payer and controls healthcare costs.
National Health Insurance Model - ANSWER: Government is the payer; Providers are private; A single-payer
model.
Out-of-Pocket Model - ANSWER: Patients pay directly for care; Also called 'self-funding'; Includes deductibles,
premiums, and co-insurance costs.
Fee-for-Service (FFS) - ANSWER: Providers receive payment for services performed.
Health Maintenance Organizations (HMO) - ANSWER: HMO providers were paid capitation payments,
restricting patients to a preferred list of providers and controlling access to care.
Health Insurance - ANSWER: Helps protect individuals from bearing the full expense of medical treatments;
offers wellness and prevention programs.
Health Insurance Inequalities - ANSWER: A significant challenge in the United States; many cannot achieve
accessible and equitable healthcare.
Risk in Healthcare Insurance - ANSWER: One of the biggest challenges; yearly health plans use actuaries to
determine premium payments.
Actuaries - ANSWER: Combine extensive data from several sources to predict the plan's cost for the coming
year.
, Premium - ANSWER: The amount you pay monthly to maintain your insurance.
Deductible - ANSWER: The amount of money you have to pay before the insurance company will share the
cost.
Copays - ANSWER: Paid by patients as part of their insurance expenses.
Insurance Risk - ANSWER: An event covered by insurance; the risk of payment is borne by the insurer.
Insurance Expenses - ANSWER: Payments such as deductibles, premiums, and copays.
Moral Hazard - ANSWER: When a consumer buys additional, unnecessary healthcare because they do not
receive the full benefit.
Adverse Selection - ANSWER: Where a consumer does not purchase health insurance until they need
coverage.
Value-based Care (VBC) - ANSWER: Provider of service awards for quality patient care.
Wellness and Prevention - ANSWER: Reduce cost and improve patient outcomes.
Healthcare Providers - ANSWER: Must transition to value-based care to reduce costs and deliver quality care.
Legislation - ANSWER: Encircled by federal, state, and local policies to keep people safe and improve
healthcare delivery.
Patient population delivery - ANSWER: Covers operations and optimization of patient privacy information.
Anti-kickback - ANSWER: When a physician receives financial incentives for referrals or drives a patient to a
specific product.
