Care Coordination and "Gatekeeper"
- The primary care provider is the gatekeeper
Example: Polly sees a nurse practitioner who discovers that the reason
... [Show More] she is
vomiting is due to the medication she is taking. The NP consults with the oncologist
to change her medication/prescription
Forces driving healthcare in the U.S.
- Biomedical model
- Financial incentive for physician specialization and hospital expansion
- Professionalism
Medicare
Medicare is for the elderly
Part A of Medicare
Hospital insurance plan for the elderly financed largely through social security taxes
from employers and employees
Part B of Medicare
Insures the elderly for physician services and is paid for by federal taxes and
monthly premiums from the beneficiaries
Part D of Medicare
Offers prescription drug coverage and is paid for by federal taxes and monthly
premiums from beneficiaries.
Medicaid
A program run by the states and is funded by federal and state taxes, which pays for
the care of millions of LOW-INCOME PEOPLE
Fee- for- Service Payment with Utilization Review
This is the traditional type of payment, with the addition that the third-party payer,
whether private insurance company or government agency, assumes the power to
authorize or deny payment for expensive medical interventions such as hospital
admissions, extra hospital days, and surgeries.
Preferred Provider Organization (PPO)
-These are organizations in which insurers' contract with a limited number of
physicians and hospitals who agree to care for patients, usually on a discounted feefor-service basis with utilization review (the insurer authorizes/denies payment for
services deemed unnecessary).
-Patients are able to see physicians not included within their insurer's physician
network if they desire, but have to pay a higher share of "out of pocket" costs as a
result when they use physicians/hospitals outside the "preferred" network.
-PPO's allow patients to choose their own providers outside of a traditional HMO
model. However, there may be increased costs to the patient in this type of model
compared with HMO models
Health Maintenance Organization (HMO) [Show Less]