CHAPTER 2: PAYING FOR HEALTH CARE
What are the four modes of financing health care? Describe each.
Describe regressive, proportional, and progressive financing. Explain how each of the following is regressive, proportional, or progressive: out-of-pocket payments, experience-rated individual private insurance, community-rated individual private insurance, health insurance purchased 100% by the employer (assuming that employees actually pay for health insurance as explained in the text), and the federal income tax.
Harvey, who has worked all his life for General Electric, reaches 65 years of age. He does not retire. Is he eligible for Medicare Part A? Part B? Six months later, his wife, who has never worked, reaches 65 years of age. Is she eligible for Medicare Part A? Part B? How are Parts A and B paid for?
Hubert has received social security disability for 24 months because he has AIDS. Is he eligible for Medicare?
Rena developed chronic renal failure and started renal dialysis 2 weeks ago. She feels fine and is working. Is she eligible for Medicare?
Heidi, aged 72 years, on Medicare Part A and B without Medicaid or a Medigap policy, is hospitalized for a stroke complicated by a deep vein thrombosis of the leg and a pulmonary embolus. She is in the acute hospital for 70 days and cared for by a family practitioner and a neurologist. She improves somewhat and is then transferred to the skilled nursing facility (SNF) for rehabilitation. She remains in the SNF for 30 days and is still severely disabled and unable to go home. She is sent to a nursing home for custodial care, where she stays for 3 months. Surprisingly, she improves and goes home, where she receives skilled physical therapy services from a home care agency and also has a homemaker come in for 4 hours a day to buy food, cook, and clean the house. She is on three prescription medications at home. What does Heidi pay and what does Medicare pay? Acute hospital? SNF? Nursing home? Home care? Physicians? Prescriptions while in hospital? Prescriptions while at home?
Discuss your experiences with health insurance that was provided through a job. How did you obtain the insurance? Did you pay part of the premium? Were there deductibles or copayments? How many choices of plans did you have? What happened if you left your job?
Divide into two groups: one insurance company selling community-rated health insurance policies and the other selling experience-rated policies. Each side should try to convince the instructor to buy its policy, first with the instructor as a young, healthy person, and then with the instructor as an older person with diabetes. Which policy is the young person more likely to choose, and which the older person?
CHAPTER 3: ACCESS TO HEALTH CARE
What are the main features of the ACA that expand health insurance coverage?
Compare access to health care for people with private insurance, for Medicaid recipients, and for people without insurance. Give examples.
Compare health outcomes for people with private insurance, for Medicaid recipients, and for people without insurance. Give examples.
What are some explanations as to why Ace Banks was healthy at age 48 while Bill Downes died at that age?
Discuss possible reasons why minority patients have poorer outcomes than white patients for many diseases.
What is the relationship between socioeconomic status (including factors such as income, education, and occupation) and health? Why does such a relationship exist?
What would be the best strategies to improve the health status of African-Americans in the United States?
CHAPTER 4: PAYING HEALTH CARE PROVIDERS
Explain each mode of physician payment: fee-for-service, episode-of-illness, capitation, and salary. Explain each mode of hospital payment: fee-for-service, per diem, episode-of-illness (diagnosis-related group [DRG]), and global budget.
How does capitation payment free insurers of risk? How does capitation payment shift risk to providers of care?
What are the arguments for risk-adjusting capitation payments?
You are a primary care physician (PCP) caring for a young woman with new onset of severe headaches and amenorrhea and a normal physical examination. What are the financial incentives and disincentives that would lead you to order or not to order a magnetic resonance imaging (MRI) scan in a case in which the need for the MRI was equivocal?
under traditional fee-for-service practice;
under fee-for-service practice with utilization review;
under an independent practice association (IPA)-model health maintenance organization (HMO) in which you receive a capitation payment that places you at risk for laboratory and x-ray studies and specialty referrals; and
under a staff model HMO that has a two-month waiting list for elective MRI scans?
In the case of the staff model HMO, what would you do if you felt you needed to obtain the MRI within 48 hours?
You are a hospital administrator and your hospital is in financial difficulty. You are about to address the medical staff, imploring them to help the hospital financially. In the old days, all you had to say was, in effect: “Admit as many patients as possible and keep them in the hospital as long as you can,” but times have changed. For some methods of payment, you want physicians to admit more patients; for others, you don’t. For some methods, you want patients to stay long, for others, you don’t. What do you tell the medical staff regarding the following:
Medicare (DRG) patients;
Medicaid (per diem) patients;
HMO (per diem) patients; and
HMO (capitated) patients.
For each of these categories of patients, does it help or hurt the hospital for physicians to
admit more patients;
keep them in the hospital more days; and
order more diagnostic studies?
CHAPTER 5: HOW HEALTH CARE IS ORGANIZED—I: PRIMARY, SECONDARY, AND TERTIARY CARE
You are 63 years old and you begin to experience chest pain when walking. You do not have a physician. A friend suggests that you need a coronary artery bypass and recommends a cardiac surgeon at the medical school. What do you do
under a dispersed model of health care delivery?
under a regionalized model?
Give some examples of the statement, “Common disorders commonly occur and rare ones rarely happen.” What are the implications of this statement for the ratio of generalist to specialist physicians in the United States?
In Great Britain and Canada, 50% of physicians are generalists. In the United States, approximately one-third of physicians are generalists (general and family practitioners, general internists, and general pediatricians). Assume you are Chair of the Health Subcommittee of the US House of Representatives Ways and Means Committee. What legislation might you propose to increase the proportion of generalist physicians?
Discuss the pros and cons of requiring everyone to enter the health care system through a “gatekeeper” health care provider (generalist physician, nurse practitioner, or physician assistant).
What are some advantages of a primary-care–based health system?
CHAPTER 6: HOW HEALTH CARE IS ORGANIZED—II: HEALTH DELIVERY SYSTEMS
What are the two generations of HMOs? Give examples of each (if possible, in your community).
What is vertical integration? What is virtual integration?
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