Ch. 9 - Health Care Systems & Policy

U.S. HEALTH CARE OVERVIEW

What are the two categories of health insurance in the United States?

1) Private

- Indemnity or Traditional fee-for-service

- Managed care (goal is to improve quality of care w/decreased costs)

2) Government/Public

- Medicare

-Medicaid

- Children's Health Insurance Program (CHIP)

- The VA system

- Department of Defense

- Indian health service

- Federal Bureau of Prisons

PRIVATE INSURANCE - Indemnity or Traditional Fee-for Service Insurance

a) How does the provider of care charge for services under private insurance?

b) Is their restricted or unrestricted access to physicians, tests, hospitals, and treatments?

c) Is it still common?

a) Provider charges a fee for each service rendered

b) Greater flexibility & unrestricted access

c) Has become relatively uncommon

PRIVATE INSURANCE - MANAGED CARE INSURANCE

a) Managed care insurance accounts for what percentage of coverage for workers?

b) What do groups of physicians share?

c) Managed Care insurance has what kind of costs?

d) Are reimbursements for dietitian services provided?

a) 99%

b) facilities and medical records

c) Fixed costs usually w/monthly premiums & co-payment for medical visits

d) May or may not provide reimbursement for dietitian's services

PRIVATE INSURANCE - MANAGED CARE INSURANCE

Managed care insurance is presented by what 4 organizations?

1) Health maintenance organizations (HMOs)

2) Preferred provider organizations (PPOs)

3) Point-of-service plans (POSs)

4) Exclusive provider organizations (EPOs)

HMOs - HEALTH MAINTENANCE ORGANIZATIONS

a) Health care insurer and Health care providers are:

b) Do members have to select a primary care physician? (PCP)

c) How are the costs?

d) How do HMOs make money?

a) one and the same

b) Yes

c) Most cost effective - fixed cost to consumer

d) By keeping you healthy (have a greater stake in your wellness than most fee-for service doctors; they avoid lengthy hospitalizations & costly services)

PPOs - PREFERRED PROVIDER ORGANIZATIONS

a) How do PPOs compare to HMOs?

b) What is the main difference between PPOs and HMOs?

c) Where can a consumer get service?

a) Similar

b) Not required to select a PCP (primary care physician)

c) Choice of getting service in-network or out-of network providers

POSs - POINT OF SERVICE PLANS

a) Members of POSs are allowed to get service from who?

b) Unlike PPOs, what do POSs encourage?

c) What is needed to see an out-of-network provider?

a) both in-network and out-of-network providers

b) POSs encourage selection of a PCP from a list of participating providers

c) Referral

EPOs - EXCLUSIVE PROVIDER ORGANIZATIONS

Is coverage flexible or limited?

The is plan generally limits coverage to care from providers WITHIN the plan's network

GOV/PUBLIC INSURANCE

a) What is the eligibility for Medicare? (5 total)

b) What federal agency administers Medicare, Medicaid, and CHIP?

a)

1) 65 years +

2) Any age with End-stage renal disease

3) Eligible for Social Security or Railroad Retirement Board (RRB) disability benefits for 24 months

4) Eligible to receive retirement benefits from SS or RRB

5) Ppl who HAD Medicare-covered government employment benefits from Social Security or RRB

b) Centers for Medicaid & Medicare Services (CMS)

MEDICARE

a) What does Medicare Part A cover? (Hint: Hospital Care)

b) What does Medicare Part B cover? (Hint: Medical Care)

c) What does Medicare Part C cover?

d) What does Medicare Part D cover?

e) What is the Medigap policy?

a) - Covers inpatient care, skilled nursing facility, hospice care, & some home health

- Deductibles & Coinsurances fees apply

b) - Optional insurance program for outpatient & preventive services

- Financed by premiums paid by enrollees & federal funds

c) - Medicare Advantage - allows private health insurance companies to provide Medicare benefits

- Must have Medicare Part A & B

- Part B premium is still paid

d) Outpatient prescription Drug benefits

e) Supplemental insurance sold by private insurance companies to help pay the deductibles, coinsurance fees, prescription drug costs, and certain services not covered by Medicare. (May be purchased if person has Medicare A & B)

MEDICAID

a) Who is Medicaid/Medi-Cal in California for?

b) What must a person's income be to be eligible?

c) What does Medicaid cover?

a) Joint state & federal program for: - low-income persons

- the aged

- blind

- disabled

- dependent children of one-parent families

- certain pregnant women and children with low incomes

b) below poverty line

c) Covers:

- Inpatient & Outpatient hospital services

- Physician

- Laboratory

- Skilled nursing home

- Home health services

- X-ray

CHILDREN'S HEALTH INSURANCE PLAN (CHIP) - Created under Title XXI of the Social Security Act

a) Who is eligible for this insurance?

b) This insurance is a partnership b/t what two entities?

c) What does this insurance cover?

a) For children in families with income ABOVE poverty line but TOO LOW to afford private health insurance

b) federal & state governments

c) Includes:

- Inpatient & Outpatient services

- Laboratory

- X-ray

- Well-baby & child care services

- Medications

- Vision Care

What are 4 other Healthcare Plans?

1) Workers' Compensation

2) Department of Veterans' Affairs (VA)

3) Public Health Service (including Indian Health Service), public health programs

4) Department of Defense - Tricare

Who are usually the uninsured? (6 total)

What percent of people were uninsured in 2013?

1) Working poor

2) Self-employed

3) Early Retirees

4) Unemployed

5) Part-time workers

6) Seasonal Workers

- 42 million people or 13% of all Americans (2013)

-Use hospital emergency room care

- Data through early 2015 suggest that the Affordable Care Act has helped expand coverage to 9 million previously uninsured people since 2013

By 2030 the number of older adults needing nursing home care will go up by how much?

It will more than triple

What was the federal total spending in 2015? and What percent made up Medicare & Health costs?

3.8 Trillion

- 27% or $1,051.8 billion made up Medicare & health costs

HEALTH CARE COSTS

What are the 7 contributors to health care expenditures?

1) An Aging population - caused major shifts in the need for services for elderly

2) Consumer awareness for health issues

3) Increased dependence on pharmaceutical products

4) Increase in technology has led to increased demand for more health services

5) Defensive medicine

6) Administrative cost of insurance process

7) Continuing advances in medicine

EFFORTS AT COST CONTAINMENT

Are characterized by what 3 trends?

1) Move away from traditional fee-for-service to newer model of managed care

2) Companies attempting to manage health care of their employees themselves - self-insured plans

3) Payers (government, insurance, employers) are setting reimbursement restrictions & limitations

EFFORTS OF COST CONTAINMENT

a) What is the Prospective Payment System (PPS)?

b) What are DRGs aka diagnosis related groups?

c) How have DRGs been assigned?

d) What is increased focus on?

e) What do DRGs encourage?

a) Uses diagnosis related groups (DRGs) codes as a basis for reimbursement (to prospectively estimate the cost of services)

b) Patients classified according to: - principal diagnosis

- secondary diagnosis

- age

- sex

- and surgical procedures

c) Assigned a relative weight reflecting cost of care

d) increased focus on outpatient services (preventive medicine) which are less costly than inpatient care

e) encourages access to care, rewards efficiency, improves transparency, and improves fairness by paying similarly across hospitals for similar care. Payment by DRGs also simplifies the payment process, encourages administrative efficiency, and basis payments on patient acuity and hospital resources rather than length of stay.

HEALTH CARE REFORM

What three variables must be examined in evaluation of Health Care?

1) Cost

2) Quality

3) Access

NUTRITION AS PART OF HEALTHCARE REFORM

Nutrition protocols serve as frameworks to help practitioners in the assessment, development, and evaluation of nutrition interventions.

1st - Nutrition Intervention (Screening/Assessment/Counseling)

2nd - Increase in knowledge, skills, and motivation

3rd - Changes in food habits

4th - Altered Risk Factors

5th - Positive outcomes - Improves Health & Well-Being

6th - Economic Benefits (Decreased health costs)

PATIENT PROTECTION & AFFORDABLE CARE ACT OF 2010

a) What did it require?

b) What does it create?

c) It is a major expansion of what?

a) - Requires that most U.S. citizens & legal residents have health insurance by 2014

- Requires employers to cover their employees or pay penalties w/exceptions for small employers

- New regulations on health plans in the private market requiring them to cover all individuals, regardless of health status (per-existing conditions)

- Greater support for prevention, wellness & public health activities

b) Creates state-based health benefit insurance exchanges through which individuals can purchase coverage & subsidies for low-income individuals

c) the Medicaid program for the nation's poorest individuals