Standard 4

1. Standard 4 Identify the types and defining features of healthcare systems in the United States. Compare and contrast these systems with those of other countries that have a high efficiency score in healthcare as rated by agencies such as the World Health Organization. Create a report and/or presentation on these comparisons.

2. Standard 5 Compare and contrast the average cost for a procedure such as childbirth, CT scan and/or heart catheterization in the United States versus the average costs in Canada, Mexico, France, Japan, and/or other countries that have high efficiency scores in healthcare. Translate the information into a table, chart, graph, or other visual representation. Cite specific textual evidence to support the analysis.

3. Standard 6 Differentiate among the methods of payment for healthcare in the United States. Include private and state or federal insurance, health savings accounts, managed care, Veteran’s Health Administration, Military Health System/TRICARE, and long-term care.

4. Health Related Costs • Health care costs are rising faster than other costs of living (12% of the Gross National Product) • Healthinsurance is an essential form of protection. • Americans spend about $2.5 trillion on health care (about $8,000/person), yet the average person would have a difficult time explaining exactly how their health plan works.

5. Health Related Costs • Insurance decreases out of pocket expenses for health care services. • Without insurance, the cost of an illness can become a financial disaster. And, will often lead to bankruptcy.

6. Health Insurance • Through Employer: • Eligibility depends upon continuous employment. • Employees must work 20 or greater hours per week, criteria set by employer. • Most companies have a waiting period before insurance benefits are available, often 90 days. • Privately Purchased: • Via ObamaCare or private insurance company. • Government Assisted: • Medicare and Medicaid (TNCare)

7. Health Insurance The Affordable Care Act (ACA) was signed into law by then President Obama in March 2010. It mandates that ALL citizens must have insurance. Under the ACA, health insurance companies can’t refuse to cover you or charge you more just because you have a “pre-existing condition” — that is, a health problem you had before the date that new health coverage starts. They also can’t charge women more than men.

8. Insurance Terminology • Premium • Payment made to insurance company each month (either by patient, employer or both) • Deductible • Amount that must be paid by the patient before the policy begins to pay • Co-insurance • Specific percentage of expenses that is shared with the insurance company

9. Insurance Terminology • Co-payment • Specific amount paid for a particular service • Preferred provider • Contract with certain doctors/hospitals for services at a reduced rate • Managed care • Preventative care, early diagnosis, second opinions; to reduce cost of care • Health Savings Accounts (HSA) • Money removed from income prior to taxes to pay for current and future medical expenses IF covered by a high deductible health plan, have no other insurance and not claimed as a dependent.

10. Types of Plans • Health maintenance organizations (HMO) • Preferred provider organizations (PPO) • Medicare • Medicaid • Worker’s Compensation • U.S. government plans

11. HMOs • Health Maintenance Organizations • A type of managed care medical insurance. • Specialty treatment is available with referral. • When a person elects to go to an HMO, these physicians provide all of their care – insured are limited to contracted physicians for care. • Out of pocket expenses are set. • Specialty care must be submitted to HMO for approval – may be denied.

12. PPOs • PPO - Preferred Provider Organizations • Physicians contract services for a set fee and is listed as a preferred provider. • The insured person chooses from preferred providers. • The insurance company pays a set amount and the insured pays a set amount called the co-payment. • Referrals are made to specialists on the list.

13. Medicare • Federal program that provides health care for almost all individuals over the age of 65 and for any person with a disability who has received Social Security benefits for at least 2 years.

14. Medicare Part A • Type A: Hospital insurance • Hospital services and care provided by an extended care facility or home health care after hospitalization

15. Medicare Part B • Type B: Medical insurance • Additional coverage for doctor’s services, outpatient treatments, therapy, and other health care. • Premiums ARE paid. • Must pay an initial deductible. • Only pays for 80% of the services; individual must pay the 20% or have another insurance policy to cover the expenses.

16. Medicare Part D • Type D: Drug coverage • subsidize the costs of prescription drugs and prescription drug insurance premiums for Medicare beneficiaries.

17. Medicaid • Medical assistance program operated by the individual states. • Benefits and individuals covered under this program vary in each state. • Usually pays for the health care of individuals with low incomes, children who qualify for public assistance, and individuals who are physically disabled or blind. • TennCare • Started in the late 1998s as a US pilot program. • Had time limits for adults without disabilities (18 months) but that requirement has changed. • Initially, required co-pays.

18. Workmen’s Compensation • Health insurance plan providing treatment for workers injured on the job. • Administered by the state, and payments are made by employers and the state. • In addition to providing payment for needed health care, this plan also reimburses the worker for wages lost because of on-the-job injury.

19. Veterans’ Health Administration (VA) • Hospitals and clinics that provide care to veterans. • The Veterans Health Administration is the largest integrated health care system in the United States, providing care at 1,233 health care facilities, including 168 VA Medical Centers and 1,053 outpatient sites of care of varying complexity (VHA outpatient clinics), serving more than 8.9 million Veterans each year.

20. Military Health Insurance/TRICARE • Insurance for all active duty military and their families, survivors of military personnel, and retired members of the Armed Forces.

21. Other Insurances • Disability • Provides income upon disability – short or long term. • Various waiting periods are available before benefits begin. • Dental • covers a portion of teeth cleaning, fillings, x-rays, orthodontics and oral surgery. • Vision • May pay a portion of an eye exam and part of a pair of glasses or contact lenses.

22. Other Insurances • Long-Term Care • Cancer • Specific insurance for the treatment of cancers. • Additional to basic health care insurance.

23. Other Insurances • Life Insurance • Provides financial payment to a beneficiary in the event of death. • Benefit can vary, depending on the needs of the family and individual. • Employers often offer life insurance to their employees in the amount of the employee's annual salary. • Individual policies can be purchased.

24. Other Insurances • Term Life Insurance – • specific amount of money will be paid to a beneficiary. • Whole Life Insurance – • a policy that allows the holder of the policy to draw on the insurance as a pension as well as having money go to a beneficiary at the time of death