1.03 PP2 Healthcare Finances

Health Maintenance Organization (HMO) - Private Provide HC services for prepaid fee Stress prevention Cheaper to prevent than treat Disadvantage is limitations placed on which doctors and facilities can be used

Preferred Provider Organization (PPO) - private A group of doctors or hospital that agrees to provide HC at a reduced rate Usually offered by large companies Offers more flexibility to patients Pts pay lower rates if they select participating physician and facility

Medicaid Govt. Federally-funded health insurance low income, children, blind or disabled.

Medicare pts over age 65 Disabled people >2yrs social Security benefits End stage renal failure There are several types of Medicare Type A Type B Type C Type D

Type A Medicare Hospital Insurance Inpatient care, skilled nursing care and home health care. funded by Social Security taxes.

Type B Medicare Medical Insurance physician services, outpatient care, etc. Patient pays premium and 20% Medicare pays 80% for services.

Type C Medicare Advantage Plans/ “MA Plans,” offered by private companies approved by Medicare plan will provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) offers extra coverage, such as vision, hearing, dental, and/or health and wellness programs Medicare pays a fixed amount, usually less than your deductible

Type C Medicare Costs Your out-of-pocket costs depend on: Whether the plan pays your monthly Part B premium. Whether the plan has a yearly deductible or additional deductibles How much you pay for each visit or service (copayments or coinsurance) The type of HC services you need and how often you use them

Type C Medicare Costs Whether you follow the plan’s rules, like using network providers Whether you need extra benefits and if the plan charges for them The plan’s yearly limit on your out-of-pocket costs for all medical services can only join a plan at certain times during the year

Type D Medicare Medicare prescription drug coverage Enroll when eligible or you may pay late fee AKA: “PDPs

Type D Medicare Costs Payments throughout the year: Monthly premium Yearly deductible Copayments or coinsurance Costs in the coverage gap Costs if you get Extra Help Costs if you pay a Late Enrollment Penalty

Traditional/Private Health Insurance Pays for all or part of a person’s health care People pay a premium Premium = monies paid for insurance contract Deductible = predetermined amount that the insured must pay each year before the insurance company will pay for an illness or injury. The amounts vary and are stated in the policy AKA: Indemnity

Tricare AKA Champus Provides care for military dependents and retired members of the armed service.

Veterans Health Administration Mission Statement To fulfill President Lincoln's promise “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the men and women who are America’s veterans. http://www.va.gov

Out of Pocket pay all costs for benefits received Some places offer discount can be price you are legally responsible for after insurance pays

Worker’s Compensation Administered by the state Pays both the medical bills and the wages for employee injured on the job Payments are made by employers and the state

DIAGNOSTIC RELATED GROUPS Pts admitted to hospitals classified in one payment group. Limit is placed on cost of care If cost of care is < the amount paid, the agency keeps the extra money If cost of care is > the amount paid, the agency must accept the loss

Organizational Structure Line of authority/chain of command Indicates areas of responsibility Goal: most efficient operation of facility Complex or simple structure determined by size and needs of organization organizational charts

Organizational Structure line of authority must be clearly indicated Workers must identify and understand their position in the structure To follow proper channels of communication, workers must take problems, reports, and questions to their immediate supervisor

Organizational Structure Allows problems to be addressed and identified by appropriate individuals If unsatisfied with a link in the chain, you may go above that person (after you have given them the opportunity to resolve your issue)

Create your structure Avie is working with her mentor at Fit Kidney. Her mentor decides Pt. Chavis is non-deserving of his dialysis and decides to stop his tx in 1 ½ hrs. instead of 4 hrs. Pt. Chavis asks Mentor why he is finished so fast. Mentor tells Pt. Chavis they have received a new dialysis machine that filters the blood in less than half the time as the old machine. The pt is excited and eager to leave. Upon attempting to leave, the pt c/o being light headed and nauseated. Avie’s mentor tells her to tell Pt. Chavis this is normal but it will go away. Avie refuses to do so and her mentor tells her to go home and not to come back. What is Avie’s Chain of command and what should she do?