Structure of the healthcare system

USA healthcare system

- largest and most complex system in the world (bigger in terms of size and money than any other country)

- no central administrative agency

- both private (53%) and public (47%)

- access to the most advanced tech and services but its dependent on insurance or ability to pay

- Per capita: US has most expensive healthcare

government-run

public healthcare is _________ (ex medicare/medicaid)

not government run

private healthcare is ________ (ex UPMC)

disparities

people who can and cannot access it

USA

most expensive country for healthcare

false

t/f: cost-effectiveness is required for market entry

USA Healthcare System

-only industrialized country without universal coverage (insurance)

ALL has access to emergency services but not routine care (pcp)

EMTALA

True

t/f: prices vary per state/service

no set prices for any service or product

profit driven

healthcare is viewed as __________, meaning payment is given for volume over quality in most instances

liability insurance

insurance that provides protection from claims arising from injuries or damage to other people or property

true

t/f: freedom to choose health care providers, but insurance may limit to who you chose as to who they will pay for

Emergency Medical Treatment and Active Labor Act

EMTALA stands for:

EMTALA

requires that medicare-participating hospitals that offer emergency services to provide a medical screening examination when a request is made

-has to access patient and will provide stabilizing treatment if needed regardless if they can pay (will get billed eventually)

patient dumping

practice by physicians and private hospitals of treating only patients who can afford their services

strengths of US healthcare

-freedom and choice

-new meds and tech

-access to emergency care

-lower taxes

-quality of providers

weakness of US healthcare

-high costs with less outcomes

-access to routine care

-volume over quality

-no administrator/vision

-lower equity (experiences are highly variable)

quality is comparable, but life expectancy is worse

how the US compares with other countries:

US is an outlier:

-substance abuse

-administrative jobs

-chronic diseases

-food system (healthy & budget)

Affordable Care Act (Obama Care)

Expanded healthcare coverage for employees and their families

uninsured

about 25 million persons (7.6 %) of all ages are _________

taxpayers (the working individuals)

Favor: limits on healthcare spending

Oppose: higher taxes

Providers (delivers the cre)

Favor: income, autonomy (make own decisions), comprehensive coverage

Oppose: limits on provider payments

Patients

Favor: comprehensive coverage, quality of care, low out of pocket costs

Oppose: limited access to care and high out of pocket costs

Employers and payers (ones paying for healthcare)

Favor: cost containment, elimination of cost shifting, administrative simplification

Oppose: government regulation

Regulators/Government

Favor: cost containment and accountability, access and quality

Oppose: provider autonomy (they want control {gov})

Access

no waiting lines, universal coverage, good geographic acces (ex. can you get an appt --> "wait 3 months")

Cost

stable healthcare costs, ability to provide new technology

(can you afford the help you are seeking?)

Quality

low rate of medical errors, improvement in outcomes (morbidity/nortality)

{when you walk in to environment, that the person is a good surgeon}

USA SHINES HERE!!

socialized medicine

when the government owns and runs the entire healthcare system (ex: VA systems, UK)

-federal land and employed by the government

single-payer system

"ONE insurance company"

-one-institution organizes financing for all care

-does not own hospitals or employ the clinicians but reimburses for their services from a single source

-"privately important"

{ex: medicare (over age 65) and Canada--> single payer system }

Private medicine

- NOT connected to the government

-private orgs and clinicians provide and pay for care

-profit driven with availability/access dependent on ability to pay

{ex: private insurance in the USA--Unitedhealthcare and Aetna}

Fee-for-service (FFS)

-Traditional model for reimbursement and for those without coverage

-provider bills for medical services delivers and is paid a pre determined rate

-AKA "indemnity insurance"

-risk is assumed by third-party payer

Capitation (by the head)

- newer model used by most private insurance companies

- providers are paid a set amount for each enrollee assigned to them

- risk is assumed by the provider