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The US healthcare is funded by a mix of
public, private, and charitable sources
Public sector
medicare, Medicaid, Indian health services, veteran’s administration, Tricare, state children’s health insurance program (S-CHIP)
Private sector
employer-based insurance, individual insurance, workers’ compensation, auto insurance
Charitable sources
organizations like the American Heart association, shriners hospitals, etx.
Medicare is
a federal program for individuals ages 65+ and certain disabled individuals, funded by federal and payroll taxes, and enrolle premiums
Madicare part A
hospital services
Madicare part B
physician sevices
Madicare part C
medicare advantage (administered by private plans)
Madicare part D
prescription drugs
What are the challenges to medicare
limited preventivie care, no coverage for dental/vision/hearing, and limited skull nursing care
Medicare overview
joint funderal-state program for low-income and disabled indiciduals
covers families iwth children, pregnant/postpartum women, older adults, and disabled individuals
funded through federal and state general funds (federal matching program)
comprehensive benefits: hospital services, physician care, family planning, lab tests
administered differently in each state
CHIP
provides health coverage for children in low-income families
CHIP was created to
address coverage gaps for children in families earning too much for medicaid but too little for private insurance
jointly funded by state and federal
focuses on precentive care and primary health services for children
premium based benefits: Group health
major employer contribution
minor employee contriution (copays deductibles)
Premium based benefits: Non-group individuals
self employed, retired, other
Premium based benefites: other
workman compensation, auto insurance
Private sector: employer-based insurance
typically offered as part of employee benefits
employees pay a portion of premiums; employers cover the test
co-sharing (co pays and deductibles vary)
coverage caries: may inslude presciptions, dental, and vision
Individual health insurance
purchased on the open market
100% premium burden on the individual
premium rated depend on health status, age, and habits
impact of ACA
workers compensation
covers work-related injuries
empoyer-paid premiums, no out-of-pocket costs
Auto insurance
covers medical costs for auto related injuries
premiums are part of auto insurance
viatical settlements
for terminally ill individuals; life insurance used for living and medical expenses
fee-for-fee sevices
payment for individual services
bundled payment models
payment for a package of services
HCPCS (healthcare common precedure coding system) is used by
CMS
ICD-10 codes
international classification by WHO
CPT codes maintained by
AMA
BPCI (bundled payment for care improvement
medicare program aimed at reducing costs by bundling payments A
ACOs (Accountable care organizations
groups of healthcare providers corrdinating care to improve quality and reduce costs for medicare beneficiaries
MACRA (medicare access and CHIP reauthorization act of 2015)
payment reform linking reimburement to quality and value
challenges in U.S helathcare
fragmented payment systems and profit-driven waste; limited access to preventive care for certain populations
Innovations in U.S healthcare
linking costs with quality and payments recorm focusing on population health and value based care
