HLTH 2030 Exam 1: Ch. 1-4, ACA

Why US Health Care (H.C.) the largest & most powerful employer in the nation

-Still getting more services

Why US H.C. growing?

-Immigration

-Aging of the population

-Expansion of health insurance under ACA (2010)

What did Affordable Care Act (ACA) 2010 lead to?

Greater utilization of health care services

To get a physician license you must

-Graduate from medical school

-Complete a supervised internship/residency program

MD

-National Board of Medical examiners

-Diagnose, prescribe, treat, surgery, cure

-Allopathic approach→ neutralize it

DO

-National Board of Osteopathic Medical Examiners

-Diagnose, prescribe, treat, surgery, cure

-Holistic approach→ whole body

-More hours clinically

Primary Care Physicians (PCPs)

-1st contact

-Longitudinal care

-Training in ambulatory care: cheaper

-Doctor offices

Specialists

-Require referral from PCPs

-Episodic care

-Training in hospitals using advance technology

Imbalance of Physicians

-Metro & Suburban concentration

-Rural & inner-city shortages

-65% specialists

Healthcare worker at risk for losing license. Why?

1. So many patients (negligence)

2. HIPPA

3. Diverting (stealing meds)

Nursing Degrees

-LPN (1 yr)

-RN (2-3 yr)

-BSN (4 yr)

High demand of nurses because?

-Increase patients : nurse staffing ratios

-Increase in new opportunities for nursing such as case management, utilization review, quality assurance, and prevention counseling

-Burn out after COVID

Midlevels do NOT:

-engage in the entire range of primary

-PAs requiring the expertise of physician

Allied Health Professions

-technicians & assistants

-less than 2 years of post-secondary education & are trained to preform procedures

-require supervision from therapists or technologists

-ensure care plan evaluation occurs as part of treatment

Health Service Administration

-Responsible for the operational, clinical, & financial outcomes of the entire organization

-Large portion of labor force

→C-suite: CEO,CFO,CNO

Public Health Professionals

Focus on the community

Public Health Trends

-Virtual care ~ telehealth

→ Problem: How should we pay providers?

-Non-physician providers: NP & PA’s

-New ways of delivering care

-Technological innovation

Health Care Teams

Professionals who use their complementary skills to provide patient care & achieve common goals good for physicians & patients

Global Health Workforce Challenges

-People are moving to US for medical school and not moving back

-Growing & Graying population: not enough

-Migration of ACWs: Procedures cheaper out there

-Medical tourism

Why does a true system not exist?

Because of privatized insurance vs. public

Americans are NOT what?

Automatically covered

Health care system is fragment:

-No follow up with patients

Lacking a central agency so:

-duplication

-overlap

-inadequacy

-inconsistency

-waste

-financial manipulation

Acceptable health care delivery system should have 3 primary objectives

1. Ensure all citizens to obtain needed health care services: ACCESS

2. Ensure patient standards are met: QUALITY

3. Ensure health services are financially obtainable: COST

US leads the world in

-Medical technology

-Medical training

-Research

-Sophisticated institutions, products, and processes of health care delivery

Financing and Insurance Mechanisms

-Employer-based health insurance (private)

-Privately purchase health insurance (private)

-Government programs (public) 1965

Medicare

-Elderly, ESRD and certain disabled people qualify for SS

- >65 years for age & any age for disability

Medicaid (state based)

-Indigent, poor

CHIP (1997)

-Children-parents cant afford

External Forces affecting H.C. delivery

• Political climate

• Economic conditions

• technology development

• social values & culture

• global influences

• Population characteristics

• Physical environment

10 reasons why American HC is different

1. No central Agency

2. Partial Access (EMTALA Act)

3. Imperfect Market

4. 3rd Party Insures & Payers

5. Multiple Payers

6. Power Balancing

7. Litigation Risks

8. High Technology (Hiterh Act)

9. Continuum of Services. (3)

10. Quest for Quality

No Central Agency: Private Means what?

-US has mostly private financing and delivery

-Private health care, hospitals, and physicians are independent of government

-No one monitors total expenses through global budgets and utilization

Public Central Agency: CMS

-US determines pubic-sector expenses and reimbursement rates for Medicare/Medicaid/CHIP

-Govt. sets standard of participation

→Providers must comply with standard to be certified to provide care for Medicaid and Medicare patients

-Regarded as minimum standards of quality

Partial Access

-Uninsured Americans

→ able to obtain medical care for acute illness

→form of universal catastrophic health insurance

→Usually forego basic and routine care

-Safety Nets

→ Not secure

Imperfect Market

-Has a quasi-market where H.C. is partially managed by free markets

-Multiple patients and providers act independently

→Providers do not collude to fix prices

→Prices are set by the interaction of supply and demand

→Inverse relationship between quantity of services demanded and price of services

→Equilibrium is achieved without interference

In a free market:

-Unrestrained competition

-Patients must have information about the appropriateness of various services to their needs

-Patients must bear cost of services received

How are consumers in a imperfect market seizing some measure of control?

-Internet as a source of medical information

Third-Party Insurers and Payers

-Patient is first party

-Provider is second party

-Intermediary is third party

Intermediary

-A wall of separation between financing and delivery

Insurance intermediary does not have an incentive to be the patient’s advocate on either price or quality

Moral Hazard

Patient go to the doctor more because they have insurance

Provider Induced Demand

Doctor/Health System orders more because patient has insurance

Multiple Payers

-System has become more cumbersome

• Difficult for providers to track various health plans

• Providers must hire claims processors

• payment can be denied for not following requirements, which necessitates rebilling

• Denied claims necessitate rebilling

• Providers may have to engage in lengthy collection efforts

• Government programs have complex regulations

Power Balancing

• Multiple players

• Key players:

  • Physicians, administrators, insurance companies, lare employers, ad the government

  • Have own economic interests to protect

  • Self-interests are often at odds

Litigation Risks

• US is a litigious society

• Private H.C. providers are increasingly susceptible

• Risk of malpractice lawsuits

• Practitioners engage in defensive medicine

  • Prescribe diagnostic tests, return checkups, documentation

High Technology

• US is a hotbed of research and innovation in new technology

  • Creates demand for new services despite high costs

  • with capital investments, must have utilization

  • legal risks for providers denying new technology

Continuum of Services (3)

1) Curative: drugs, surgery

2) Restorative: PT, OT, Speech therapist

3) Preventative: Wellness visit, mammogram, prenatal care

• US is loopsided, with a heavier emphasis on specialized services than on preventative services, primary care, & management of chronic conditions

Quest for Quality

• Definition & measurement are not clear-cut

• Higher expectations

• Continuous quality improvement

Trends & Directions in H.C. delivery

• More Telehealth

• More midlevels, health coaches, & health info technology

Challenges:

• Managing costs,

• Focus on care delivery,

• Adopting tech,

• New operating models,

• Meeting various federal & state regulations

H.C. Systems of Other Countries (3)

• National health insurance (NHI)

• National health system (NHS)

• Socialized health insurance (SHI)

Quality of Life

• The satisfaction during & following H.C. delivery system encounter

• Based on perception

Basic Concepts of Health

• Trying to get to Holistic health

• Biopsychosocial model

  • Physical, social, spiritual, & mental

Risks Factors & Disease

• Acute, subacute, & chronic conditions

• acute: short lasting, episodic. Ex. heart attack

• sub: post acute treatment→ uninary cather

• chronic: long lasting → diabetes, COPD, HIV

3 Reasons for the Rise

• New diagnostic methods, procedures, & pharmaceuticals

  • People are living longer so more of a chance to get smth

• Screening & diagnosis

  • Catching it sooner

• Lifestyle choices: Fast food (convience), “sitting disease”

Health Promotion & Disease Prevention- 3 Principles

1. Health risk appraisal

2. Interventions for counteracting the key risk factors

3. Adequate public & social services

2. Interventions for counteracting the key risk factors

• Primary: H.H., immunizations

• Secondary: “you have it”, medicines, x-rays

• Tertiary: (iatrogenic) disease→ doesn’t lead to another disease

Factors that Affect Health & Well-being

• Genetics

• Health care

• Environment

• Lifestyle

Measures of physical health

• Morbidity

• Mortality

• Longevity

• Disability

Measures of Demographic

• Births

• Migration

Measures of social health

• Breslow’s social health dimensions

• Social contacts and social resources

Breslow’s

• Are you employed? Married? Occupied?

  →Social interactions

Social Contracts

• Do you have someone you can rely on?

→Social resources

Market Justice: “The Economic Good”

• Focus on individual rather than a collective

• Does not always protect society

• Does not work well in health care delivery

Social Justice: “The Good Society”

• The equitable distribution of health care is society’s responsibility

• Health care is a social good

• Health care should be based on need rather than cost

• There is a shared responsibility for health

• Govt. known what is best planning and distribution

Healthy People Initiatives: 5 goals

• Attain healthy, thriving lives and well-being, free of preventable disease,
  disability, injury, and premature death.

• Eliminate health disparities, achieve health equity, and attain health literacy to
  improve the health and well-being of all.

• Create social, physical, and economic environments that promote attaining the
  full potential for health and well-being for all.

• Promote healthy development, healthy behaviors, and well-being across all life
  stages.

• Engage leadership, key constituents, and the public across multiple sectors to
  take action and design policies that improve the health and well-being of all.

4 main pillars

• Preindustrial

• Post industrial

• Corporate

• Health Care Reform

Preindustrial Era (late 1800s)

• No health insurance

• Travel made it impossible for doctors to see patients

• Barter system

Preindustrial Era-Medical training

• 2 year of MD degree

• Went through apprenticeship

Preindustrial Era- Medical Practice

• A trade without prestige

• anyone could do it: layperson. Ex. Barbers did bloodletting

• Income from medical practice alone was inadequate to support a family

Preindustrial Era-Medical Institutions

• Hospitals=death houses (75%)

• State gov. operated asylum for patient with chronic mental illness

• Almshouses = poorhouses

  → run by gov.

• Pesthouses were operated to isolate people (infectious diseases)

• Dispensaries were staffed by medical students

Postindustrial Era (1800s-1980)

• Creation of health insurance

• private→public 1965

Postindustrial Era- Medical Profession

• Urbanization:

  • Office-based practice began to replace house calls

• Medicine became driven by science & tech, outside the domain of laypeople

• Bias toward specialization in medical practice

• Groundbreaking medical discoveries further legitmized the medical profession

• Increase cost of medical care

Postindustrial Era- Educational Reform

Because of advances in medical science

• 1870, medical schools started affiliating with universities

• Harvard revolutionized medical education, adopted European model

  • 4 to 9 month academic years

  • Medical instruction went from 2 to 3 years

  • chemistry, physiology, anatomy, & pathology

• John Hopkins opened

  • college degree requirement

  • training became a graduate program

  • residency training

• Flexner Reported point to inconsistencies in medical education

• Council on Medical Education created by the AMA: Accreditation of medical schools

AMA

• Galvanize the profession & protect the interest of physicians

• The concerted activities of physicians through the AMA is referred to as “organized medicine”

  • Gained power by controlling medical education

  • Supported states in establishing medical licensing laws

  • Discouraged employment of physicians by hospitals and insurance companies

Postindustrial Era-Development of Hospital

• Rise in Hospitals = symbolize the institutionalization of H.C.

• Advancements in medical science created the need to centralize expensive facilities and equipment in an institution

→ Nursing improved hospital care

Postindustrial Era- History of Health Insurance

• Workers’ compensation

• Rise of private health insurance

• Failure of health care proposals

• Creation of Medicaid and Medicare

• Managed Care organizations

• ACA

Postindustrial Era-Workers’ Compensation

• Was the first broad-coverage health insurance in the US
  Was orginally designed to make cash payments to workers for wages lost because of job-related injuries and disease

• Later became compensation for medical expenses, and death benefits for survivors were added

• was a trial balloon for the idea of govt.-sponsored health insurance

Postindustrial Era- Rise of Private Health Insurance

• Private insurance began as a form of disability coverage that provided income during temporary disability due to bodily injury or illness

• Medical treatments and hospital care advance, but medical care also became more expensive

Postindustrial Era- Hospital Plan: and Birth of Blue Cross

• GD made hospitals economically unstable

• Individuals faced the loss of income from illness and the debt of high health care costs.

• 1929 a hospital insurance plan for teachers at Baylor Uni. → It became the model for Blue Cross plan around the country

• The AHA supported group hospital plans & coordinated them into a Blue Cross network

  • 1st privatized plan and ONLY for hospitals

Postindustrial Era- 1st Physician Pland & the Birth of Blue Shield

• Doc visits

• 1939: Cali Medical Assoication started the 1st Blue Shield plan + 1974 Cross & Shield merged

  • They are a joint corporation & are in almost every state

Postindustrial Era- Employer-Based Health Insurance

• WWII, employees accepted employer-paid H.I. to compensate for the loss of raise

• Company did not have to pay taxes

• Supreme Court ruled in 1948 that employee benefits were a legimate part of union-management negotiations

• 1954, Congress made employer-provided health coverage nontaxable

  → Equivalent to getting more salary w/o having to pay taxes

Postindustrial Era- National H.I.

• Failed because for labor & political stability in the US

• Decentralized American system gave the U.S. fed govt. little direct control over social policy

• Middle-class Americans havebeen aerse to higher taxes to pay for the rise cost of a national health care program

Postindustrial Era- Creation of Medicaid & Medicare

• Kerr-Mills Act-Failed

  → Medicare > 65, low-income

• Medicare war upheld by broad grassroots support & being attached to social security

• Before 1965, private H.I. was the only widely available source of payment for health care

  → available primarily to middle-class working people and their families

• 3 part program waas adopted to serve two distinct populations:

  • Medicare Parts A & B- Title 18 SS act

  • Medicaid- Title 19 SS act

Postindustrial Era- History of Insurance: Private

• Private health insurance is
  also called “voluntary
  health insurance.”

• Referred as
  members/enrollees

• Single or family plans

Postindustrial Era- History of Insurance: Public

• Publicly financed Medicare
  and Medicaid were created to
  meet the medical needs of the
  elderly and the poor,
  respectively

• Called beneficiaries

• Single plans

Postindustrial Era- Creation Medicaid and Medicare

• Medicare Part A was designed to use Social Security funds to finance hospital care for elderly

• Medicare Part B was designed to cover physicians’ services through government-subsidized insurance.

  • The elderly would pay part of the premiums.

• Medicaid reflected sharply different traditions: low-income

• Uniform national standard for eligibilty & benefits: federally

• Medicaid benefits vary from state to state

• Medicare & Medcaid program are financed by the govt

  → Beneficiaries recieve health care service mostly from private hospitals, physicians, & other providers

• CMS controls money

The Corporate- Corporatization

• Medical care has become the domain of large corporations

• Managed care has become the primary vehicle for insurance and delivery

• Integrated delivery systems

• Physicians have consolidated into larger group practices and hospital partnerships

The Corporate: Information Revolution

• Telemedicine: Integration of tele-communication systems into distance care giving

• E-health: Info & services over the internet, empowered consumers

The Corporate: Globalization

• Cross-border activities

  • Cross-country telemedicine

  • Recieving health care aboard (medical tourism)

  • Foreign direct investment in health care enterprises

  • Migration of health professionals

Health Care Reform-Infancy

• Major changes undertaken by the govt. to expand health insurance to the uninsured & regulate the financing and delivery of health care

  • Numerous new regulations are made

  • the govt.’s regulatory bureaucracy is expanded

  • The govt. controls various aspects of health care delivery

Health Care Reform- Affordable Care Act

• Most sweeping reform since Medicare and Medicaid

• The law was passed by the Democratic majority in Congress.

• The controversial law triggered lawsuits.

• The U.S. Supreme Court upheld the constitutionality of the law but left the option of expanding Medicaid to each state.

Health Care Reform- 6 Factors in passing of ACA

• Democratic party held presidency and majorities in Congress ?
• Public option was dropped ?
• Closed door deliberations x
• Benefits were overstated x
• Backing of major industry representatives: good
• Obama tied reform proposals to economic growth: good

Health Care Reform- Patchy legacy of the ACA

• Patchy legacy of the ACA

  • Partially reduced number of uninsured Americans.

  • Medicaid accounted for roughly 60%

  • 40% attributed to income-based federal subsidies.

  • Required residents to have minimum coverage or pay penalty tax.

  • Many Americans did not benefit.

  • Many lawsuits

• Prospects for new reforms

Health Care Reform- Challenges and Current Staus

• Most Supreme Court cases were decided in favor of the ACA but not all
• Tax Cuts and Jobs Act, 2017 repealed the individual mandate
• Full repeal and replacement is highly unlikely
• Most Americans now sort-of approve of the ACA, but want changes
• Trump made several reforms although the political environment had remained hostile

Health Care Reform- Change from Trump in Office

• Approval of more generic drugs
• Measures in place to stop rising Rx costs
• More Medicare Advantage Plans (Medicare Part C)
• Transparency in health costs

ACA: Why Now: Commitment

• Learned from failed health reform efforts
• Clinton did not move quick enough after his 1992 election
• Sidetracked with other issues: Plan not presented until a year into presidency
• Obama charged ahead with health reform even though he had to also tackle the issue of the economy and possible collapse of the financial sector.
• The Democratic party had the majority, but it wouldn’t last long

ACA: Interest Groups and COngress

• Obama made deals with various stakeholders that got big industries on board.
• American Hospital Association, Pharmaceutical Research and Manufactures of America
• He set out his principles but left the work of drafting a bill and fleshing out the details to Congress

Key Provisions to the ACA

• Changes to private insurance

• Closes the Medicare prescription “doughnut hole”

• Expands coverage + impose individual mandate in 2014

Changes to private insurance

• Kids cant be denied health coverage if they are sick

• young adults on parents’ policies to age 26

• Prohibit lifetime home monetary caps

• Minimum medical loss ratio

Closes the Medicare prescription “doughnut hole”

• Medicare Part D

Expands coverage + impose individual mandate in 2014

• Expands Medicaid to 138% of FPL

• Exchanges