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C425 WGU Study Areas – Complete Study Guide
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C425 WGU Study Areas – Complete Study Guide
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C425 WGU Study Areas – Complete Study GuidePatient Protection and Affordable Care Act in 2010 - ✔️ of 2010
presages a gradual shift from market justice to social justice in the U.S.
health care system.
-1.Individuals are mandated to have health insurance, and tax penalties are
levied for not having health insurance.
2.Employers with 50 or more employees are mandated to offer insurance
coverage or pay a "free rider" tax.
3.Medicaid is expanded to cover all people at or below 133% of the federal
poverty level (FPL).* People with incomes up to 400% of FPL will get
premium subsidies from the government.
4.States are mandated to establish health insurance exchanges through
which small groups and individuals can purchase health insurance.
5.A sliding-scale tax credit is allowed for small businesses with fewer than
25 workers.
6.It is illegal to deny health insurance to people with preexisting medical
conditions.
-Ironically, despite these provisions of the ACA, approximately 21 million
people will remain uninsured according to estimates by the Congressional
Budget Office
Managed care is? - ✔️ system of health care delivery that (1)
seeks to achieve efficiency by integrating the basic functions of health care
delivery, (2) employs mechanisms to control (manage) utilization of
medical services, and (3) determines the price at which the services are
purchased and, consequently, how much the providers get paid. Managed
care is the dominant health care delivery system in the United States today
and covers most Americans in both private and public health insurance
programs.
The terms "outpatient" and "ambulatory" are used ? - ✔️
interchangeably, although the term "outpatient" is more comprehensive.
Strictly speaking, ambulatory care consists of diagnostic and therapeutic
services and treatments provided to the "walking
CHARACTERISTICS OF THE U.S. HEALTH CARE SYSTEM - ✔️ -No
central governing agency and little integration and coordination (Most
,developed countries have centrally controlled universal health care
systems that authorize the financing, payment, and delivery of health care
to all residents. In contrast, the U.S. system is not centrally controlled; it is
financed both publicly and privately and, therefore, features a variety of
payment, insurance, and delivery mechanisms. Private financing,
predominantly through employers, accounts for approximately 54% of
total health care expenditures; the government finances the remaining
46%..Centrally controlled health care systems are less complex than the
U.S. health care system. They are also less costly because they can manage
total expenditures through global budgets and can govern the availability
and utilization of services)
•Technology-driven delivery system focusing on acute Care (The United
States is a hotbed of research and innovation in new medical technology.
Growth in science and technology often creates a demand for new services
despite shrinking resources to finance sophisticated care...Although
technology has ushered in a new generation of successful interventions, the
negative outcomes resulting from its overuse are many.)
•High in cost, unequal in access, and average in outcome(The United States
spends more than any other developed country on health care (primarily
medical care), and costs continue to rise at an alarming rate. Despite
spending such a high percentage of the nation's gross domestic product
(16% in 2008 and 17.6% in 2009) on health care, many U.S. residents have
limited access to even the most basic care )
•Delivery of health care under imperfect market conditions (In the United
States, even though the delivery of services is largely in private hands,
health care is only partially governed by free market forces. Hence, the
system is best described as a quasi-market or an imperfect market.The
following key characteristics of free markets help explain why U.S. health
care is not a true free market.
In a free market, multiple patients (buyers) and providers (sellers) act
independently. In a free market, patients should be able to choose their
provider based on price and quality of services.)
•Government as subsidiary to the private sector (In most other developed
countries, the government plays a central role in delivering health care. In
the United States, the private sector plays the dominant role.)
•Fusion of market justice and social justice
•Multiple players and balance of power
•Quest for integration and accountability
•Access to health care services selectively based on insurance coverage
,•Legal risks influence practice behaviors
Access - ✔️ refers to the ability of an individual to obtain health
care services when needed. In the United States, access is restricted to
those who (1) have health insurance through their employers, (2) are
covered under a government health care program, (3) can afford to buy
insurance out of their own private funds, (4) are able to pay for services
privately, or (5) can obtain services through safety net providers
Imperfect Market Conditions - ✔️ Under national health care
programs, patients may have varying degrees of choice in selecting their
providers; however, true economic market forces are virtually nonexistent.
In the United States, even though the delivery of services is largely in
private hands, health care is only partially governed by free market forces.
Hence, the system is best described as a quasi-market or an imperfect
market. The following key characteristics of free markets help explain why
U.S. health care is not a true free market.In a free market, multiple patients
(buyers) and providers (sellers) act independently. In a free market,
patients should be able to choose their provider based on price and quality
of services. If matters were this simple, patient choice would determine
prices by the unencumbered interaction of supply and demand. In reality,
however, the payer is an MCO, Medicare, or Medicaid, rather than the
patient. Prices are set by agencies external to the market; thus they are not
freely governed by the forces of supply and demand.For the health care
market to be free, unrestrained competition must occur among providers
on the basis of price and quality.
Need - ✔️ -has generally been defined as the amount of medical
care that medical experts believe a person should have to remain or
become healthy.
-decisions about the utilization of health care are often determined by need
rather than by price-based demand.
Government as Subsidiary to the Private Sector - ✔️ In most
other developed countries, the government plays a central role in
delivering health care. In the United States, the private sector plays the
dominant role. This arrangement can partially be explained by the
American tradition of reliance on individual responsibility and a
commitment to limiting the power of the national government.
, social justice - ✔️ social justice emphasizes the well-being of the
community over that of the individual; thus the inability to obtain medical
services because of a lack of financial resources is considered unjust.
market justice - ✔️ -Individual responsibility for health.
-Benefits are based on individual purchasing power.
-Limited obligation to the collective good.
-Emphasis on individual well-being.
-Private solutions to social problems.
-Rationing based on ability to pay.
Demand-side rationing (price rationing) - ✔️ Indirect rationing
that occurs when not everyone has health insurance.
-Prices and ability to pay combine to ration the quality and type of -
healthcare services people consume.
Supply-side rationing (planned rationing) - ✔️ Restricting the
availability of expensive medical technology and specialty care.
Also called 'planned rationing' that is generally carried out by a
government to limit the availability of health care services, particularly
expensive technology.
When the government makes deliberate attempts to limit the supply of
healthcare services, particularly those beyond the basic level of care.
Canada - ✔️ the government finances health care through general
taxes, but the actual care is delivered by private providers.
-Canada's national health insurance system, referred to as Medicare,
Great Britain - ✔️ the government manages the infrastructure for
the delivery of medical care, in addition to financing a tax-supported
national health insurance program. Under such a system, most of the
medical institutions are operated by the government. Most health care
providers, such as physicians, are either government employees or are
tightly organized in a publicly managed infrastructure.
Germany - ✔️ health care is financed through government-
mandated contributions by employers and employees. Health care is
delivered by private providers. Private not-for-profit insurance companies,
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