How are health care costs managed and controlled?

How are health care costs managed and controlled?

Health Care Finance Models There are two broad approaches to financing health care: a market-based approach and a government-financed approach. Answer the 12 questions, providing 3-4 sentences minimum for each approach.   Include any references used at the end of the chart.
Market-based (HMO, POS, PPO, etc.) Government-financed (Medicare, Medicaid, Tricare, etc.)
Who is provided access? Access is provided to those who are covered by an employer based health care plan. Some supplemental plans such as Medicare Advantage may also provide access to these market based and third party payers and administrators. Medicare access is provided to those who are elderly, disabled and blind. Medicaid access is provided to those who fall into low income (below 133% FPL), children, and pregnant women. Tricare access is provided to those who are employees of the Federal government, veterans, active duty and retired members of the armed forces, their dependents, survivors, and former spouses.
How much coverage is provided? Coverage provides medical, dental, vision, and some long term care. Supplemental plans for Medicare may offer routine vision, hearing and dental care. This care is excluded from Original Medicare. Some plans cover wellness programs and preventative care programs that may include things like a gym membership.   Mandatory benefits include inpatient and outpatient hospital services, lab and x-ray, and home health services. Some optional benefits include prescription drugs, case management, physical and occupational therapy.
How are the services paid for? Services are paid by employer and employee contributions. Self-payers who can afford the high costs of out of pocket premiums. Services are paid for by state and federal government contribution which are generally taxpayer dollars.
How does reimbursement apply? Fee for delivery of services and the actual payment after services have been rendered. These fees are predetermined and agreed upon by providers who accept these insurance plans. Some services are billed separately and may be the responsibility of those receiving services. Reimbursement by RVUís, bundled services, PPD for inpatient stays, capitation which pays providers monthly for patients with Medicare. Private insurers usually follow suit of reimbursement types for Medicare. Cost and value based.
Are there limitations of care? Limitations extend to type of care, cost of care and coverage. These plans have higher costs due to availability of care provided and technology used for care, Supply and demand often contribute to these higher costs. Limitations of care extend to limited number of providers willing to accept lower reimbursement rates from state and federal issued insurance plans. Fixed costs and value based care often limit exposure of advancements of care to patients.
What guides care decision for patients? Care decisions are guided by availability of providers and services. Costs are also a consideration for care decisions. Complexity and variability of the individualís illness along with multiple decision-making milestones. Care decisions are guided by availability of providers and services. Complexity and variability of the individualís illness along with multiple decision-making milestones. May lead to moral hazard due to lack of co-pays or out of pocket expenses.
What is the quality of services (use HEDIS website for answer)?    
Are there competitive options?    
How much are prevention and wellness emphasized and measured?    
How are health care costs managed and controlled?    
How are medical advances generated?    
How is health care reform established?    

ANSWER.

PAPER DETAILS
Academic Level Masters
Subject Area Nursing
Paper Type† Assignment
Number of Pages 1 Page(s)/275 words
Sources 3
Format APA
Spacing Single Spacing

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