HEALTHCARE SYSTEM MIDTERM
Intro to Healthcare Reform
Emphasizes that much of healthcare is affected by factors beyond individual control.
Social Determinants of Health: Non-medical factors that significantly impact health outcomes.
Conditions in which individuals are born, grow, live, work, and age strongly influencing health outcomes.
Responsible for causing diseases and affecting life expectancy and risk.
Examples of Social Determinants:
Income
Education
Housing
Food access
Neighborhood
Employment
Social environment
Collectively, these determinants have a strong influence on life expectancy and disease risk.
Social vs. Economic Factors
Distribution of influence on health outcomes:
Social determinants account for 80%.
Healthcare/medical care accounts for 20%.
Genetic factors and biology also contribute.
Conclusion: Majority of health outcomes are influenced by social conditions rather than solely medical care.
Health Disparities
Definition: Avoidable differences in disease burden among socially disadvantaged populations.
Differences in:
Disease burden
Access to care
Quality of care
Health outcomes
Examples of Factors Leading to Health Disparities:
Race
Gender
Disability
Income
Geography
Healthcare Disparities
Definition: Unfair differences in access and quality of care among socially disadvantaged groups.
Emphasizes these disparities reflect access differences rather than quality or outcomes.
Triple Aim of Healthcare
Focuses on three goals for improving healthcare systems:
Improve quality of care
Improve access to healthcare
Reduce healthcare costs
Importance of Healthcare
Impacts:
Everyone in society.
Influences various sectors including:
Economy
Politics
Workforce
National spending
Economic stability
Connections to Other Fields:
Integrates interests of medicine, public health, business, and government.
Healthcare as a Privilege vs. a Human Right
In the U.S., access often depends on:
Employment status
Ability to pay
Eligibility for programs.
Universal Declaration of Human Rights:
Asserts a right to:
Standard of living
Adequate medical care
Current U.S. Reality:
No universal right to healthcare exists.
Absence of a public option.
Insurance must be purchased.
Affordable Care Act (ACA): Attempted reforms but did not establish national healthcare.
Health Insurance vs Health Care
Health Insurance:
Acts as a financing mechanism for healthcare.
Provides access to clinical services but does not guarantee good health outcomes.
Health Care:
Refers to the clinical services provided to patients.
Important Points:
While insurance improves access and contributes to early diagnosis and better chronic illness management, it does not solely determine health outcomes.
Overemphasis on the relationship between insurance and health outcomes neglects social determinants and ongoing disparities.
Universal Healthcare in the U.S.
The only industrialized country without universal healthcare.
Lacks a public option for insurance coverage.
Paradox of Healthcare
U.S. has:
Advanced innovation and research capabilities.
Highest spending on healthcare.
Despite investment, U.S. faces poor health outcomes, including:
Shorter life expectancy
Higher infant mortality rates
Increased prevalence of chronic illnesses
Rising obesity rates
Increase in drug-related deaths.
Note on low-income populations: Their health statistics bring down national averages.
Cost Sharing in Healthcare Coverage
Coverage costs involve various stakeholders:
Patient
Employer
Government
Key Components in Health Insurance:
Premium: The annual fee for coverage, often paid monthly and variable by plan.
Deductible: Fixed amount that must be paid before insurance contributes to costs.
Co-insurance: Percentage of costs that patients must pay after reaching the deductible.
Sources of Coverage in the U.S.
Coverage Statistics:
Approximately 50% from employers.
Approximately 35-40% from government programs (Medicare/Medicaid).
8-10% uninsured.
Some individuals pay out-of-pocket for services.
Barriers to Access
Factors that inhibit access include:
Insurance status
Costs
Job loss/change
Eligibility issues
Documentation requirements
Complexity of applications
Literacy levels impacting understanding.
Underinsured:
Individuals who have insurance but face challenges due to:
High deductible
High co-insurance
Inadequate coverage
Affordability issues.
Volume vs Value Driven Healthcare System
Volume-Based Care (Fee-for-Service):
Model pays providers per visit; incentivizes more services for higher revenue.
Value-Based Care:
Financial incentives on quality, health outcomes, and patient health.
Bundled Payments: Flat fee for a complete episode of care, retrospectively reimbursed after service.
Changes to Reimbursement (under ACA):
Aims to incentivize better health outcomes, reduce spending, and improve care quality.
DRGs (Diagnostic Related Groups)
Reimbursement strategy where providers are compensated based on diagnosis.
Impact of Coding: Proper diagnostics coding affects reimbursement amounts.
Historical Context of U.S. Healthcare
Pre-Industrial Era:
Characterized by domestic remedies and no professional healthcare providers; few hospitals existed and quality was poor.
Post-Industrial Era:
Organized medicine emerged with the opposition from the American Medical Association (AMA) to universal coverage.
Employer-based insurance developed along with Medicare and Medicaid, leading to improved standards in medical education.
Influence of the Flexner Report on medical schools.
Corporate Era:
Transition involving corporatization, advancements in technology, globalization, and foreign investment.
Emergence of exclusion of low-income individuals based on ability to pay.
Reform Era:
Marked by the passage of the Affordable Care Act and historical failures, including attempts to establish similar safety nets as Social Security, CHIP, and Part D.
Types of Health Insurance in the U.S.
Private For-Profit Insurance:
Owned by investors; seeks to generate shareholder profits.
Private Non-Profit Insurance:
Revenue is reinvested in community health.
Public Options:
Funded by government sources, include Medicare and Medicaid.
Out-of-Pocket Payments:
Transactions made directly for healthcare.
Combo Payments:
Mixed coverage that includes different forms of coverage.
Overview of Providers and Financing
Approximately 1000 insurance companies operate.
Roughly 470 Health Maintenance Organizations (HMOs)
Require patients to utilize in-network providers.
Around 750 Preferred Provider Organizations (PPOs)
Offer more flexibility at a higher cost.
Employment role in funding:
Employers contribute to insurance costs alongside taxes, with individuals purchasing individual policies.
Global Comparison of Healthcare Systems
U.S. Healthcare:
Unique for having no universal healthcare; faces worse outcomes, with medical bankruptcy being common.
Beveridge Model:
Funded by government through taxes, operates on a single-payer system, similar to a national health service.
Bismarck Model:
Funded through employer and employee contributions, primarily relies on private insurance mechanisms.
Economic Functions in Healthcare
Market Justice:
Concept based on ability to pay and free market principles, prioritizing innovation and capitalism.
Social Justice:
Advocates for fair distribution of healthcare resources with community needs prioritized, evidenced through programs like Medicare and Medicaid.
Current System:
Hybrid of market and social justice models.
Triple Aim Revisited
Cost: Examines the price and cost-sharing structures for services provided.
Quality: Evaluates health outcomes concerning mortality and morbidity rates.
Access: Criteria for who receives care based on costs, expertise, and geographical availability.
Medicare Overview
Established following opposition from the AMA.
Coverage primarily for individuals aged 65 and above.
Funded through payroll taxes with four parts:
Part A: Hospital services
Part B: Outpatient care
Part C: Medicare Advantage plans
Part D: Prescription drug coverage.
Current Issues:
Aging population increases demand, leading to questions about sustainability and dual eligibility complications.
Medicaid Overview
Joint program between state and federal governments.
Income-Based insurance, largest insurer of long-term care.
Expanded under ACA, although some states opted out.
FMAP: Federal matching assistance percentage.
Affordable Care Act (ACA) Components
Introduced key strategies:
Subsidies for lower-income individuals.
Guaranteed issuance of insurance policies.
Initial individual mandate (later removed).
Employer mandate requirements for larger businesses.
Medicaid expansion provisions.
Establishment of marketplace exchanges for insurance procurement.
Timeline of Key Events:
2008: Approximately 46 million uninsured people.
2010: ACA legislation passed.
2014: Major provisions implemented.
2017: Penalty for the individual mandate removed by Congress.
Supreme Court Findings:
Upheld the constitutionality of the mandate.
Declared Medicaid expansion optional for states.
Ethical Considerations and Issues
Principally focused on:
Fairness and equity in healthcare access.
Discusses the paradox of healthcare dynamics.
Examines issues of structural racism and the legacy of segregation.
Politics as a determinant in healthcare policymaking.
Comparative Healthcare Insight
United Kingdom: Operates under a single-payer system, with lower costs and higher life expectancy, but longer wait times.
Switzerland: Offers universal coverage at a higher cost, providing choice among health plans.
Effect in America: Highlights risks of bankruptcy, high healthcare costs, and prevalence of preventable deaths.
Documentaries and Historical References
Power to Heal:
Discusses civil rights and impact on healthcare access through legislation like the Hill-Burton Act and cases such as "Brown v. Board of Education".
Civil Rights Act: Led to Medicare's role in forcing hospital desegregation; closure of many historically Black medical schools.
Quiz Review Information
Market Justice: Related to ability to pay for services.
One Health Concept: Emphasizes the interconnectedness of human, animal, and environmental health.
Financing Sources: Include government, employer contributions, out-of-pocket expenditures, DRGs, and bundled payments.
Reasons for U.S. Poor Health Outcomes:
Aging population.
Reliance on third-party payments.
High administrative costs.
Defensive medicine practices.
Variance in medical practice across regions.