Health Administration Press Notes

Health Administration Press Agenda for the Week

  • Chapter 8 in Wagner: Another top 5 important chapter!

  • Exam #2:

    • Review will occur when everyone has taken it; expected average is probably 83%.

  • No Chapter Quiz:

    • Instead, there is a Short Answer Essay on Potential Solutions to US Healthcare Problems.

    • Due by 11:59 PM March 9; worth a maximum of 10 points.

    • Link provided for submission.

See Also for This Week

  • U.S. Health Care Rankings by State 2025 | Commonwealth Fund:

    • A commendable report card within the US, avoiding comparisons with disparate European systems.

  • Example of Culturally Competent Care:

    • Alivio Medical Center as an exemplar of primary care.

  • CMS Provider Directory Beta Launch:

    • Becker's Payer Issues article discusses a comprehensive directory of provider choices and evaluations.

    • Inquiry into efficacy compared to HealthGrades.com and similar platforms.

  • CMS Lessons from Accountable Health Communities Model:

    • Insights from non-medical support systems including transportation assistance for patients.

Integrity of Testing

  • Course Policy Update:

    • LockDown Browser is mandated for all testing.

    • Specific seating arrangement; not allowed behind row ____.

  • Attendance Policy:

    • Mandatory written signature on the roster sheet.

  • Grading Policy:

    • In light of widespread illness, one quiz score will be dropped; reflected in Canvas as “Excused.”

    • Increase in allowable excused absences from 2 to 3 for any reason.

    • Encouragement to review grades in Canvas regularly.

    • Mention of attendance being a significant indicator of grading performance.

    • Acknowledgment of Canvas engagement also being a grade indicator.

Health System Dashboard

  • Peterson- KFF Health System Tracker:

    • Provides extensive details pertinent to U.S. healthcare.

  • Commonwealth Fund:

    • Focused on broad healthcare issues and international comparisons but with less detailed data than KFF.

Health Policy 101 Introduction | KFF

  • A powerful resource, recently updated in October 2025, to delve deeper into specific US healthcare areas.

Foundations of the American College of Healthcare Executives

  • Title: The United States Healthcare System

  • Overview of healthcare drive forces and future outlook by Stephen L. Wagner

Chapter 8: Financing a Massive System

  • Conceptual focus on payers/insurers.

  • Discussion on questions and concerns prompted before diving into this chapter (Participants include Josh, Eli, Robert, Qualyn).

Structure and Flow of Money

  • Referenced from Askin E. and Moore N. The Healthcare Handbook, 3rd ed. 2024.

  • Emphasis on understanding the structure and financial transactions in the healthcare system over the semester.

ISPOR - US Healthcare System Overview

  • Objective: Understand decision-makers and influencers in healthcare.

  • Use provided slides to connect various healthcare professionals and systems.

Color Codings and Healthcare Economics

  • Part C: Demonstrates adverse selection effects attracting a sicker population, which results in unanticipated higher costs for insurers.

Major Healthcare Stakeholders

  • Color-coded interrelation diagram depicting relationships among decision-makers.

Regulatory and Policy-Making Stakeholders

  • U.S. Department of Health and Human Services (HHS):

    • Tasked with protecting health and providing essential human services to all Americans.

    • Several agencies under HHS are responsible for developing health policies and managing healthcare expenditures through CMS.

    • Absence of strict federal- or state-wide healthcare expenditure targets.

Key Agencies Under HHS

  • Agency for Healthcare Research and Quality (AHRQ):

    • Mission to produce safer, higher quality, equitable, and affordable healthcare.

  • Centers for Disease Control and Prevention (CDC):

    • Provides leadership for disease prevention and control; pivotal in responding to health emergencies.

  • National Institutes of Health (NIH):

    • Supports biomedical and behavioral research; conducts research and promotes medical knowledge sharing.

  • Office of Inspector General (OIG):

    • Protects integrity of HHS programs and welfare of participants.

  • Food and Drug Administration (FDA):

    • Oversee safety of food and efficacy of drugs and devices while approving regulatory processes.

Healthcare Payer Structures

  • Medicaid:

    • Joint federal-state program providing healthcare coverage to patients with limited resources, primarily low-income individuals.

    • Managed by states that determine eligibility.

  • State Children's Health Insurance Program (CHIP):

    • Provides low-cost health coverage for children in families exceeding Medicaid qualification.

    • States have flexibility in coverage details but must provide comprehensive coverage.

  • Veterans Health Administration (VHA):

    • Federal healthcare system supported by the Department of Veterans Affairs; serves veterans through a network of facilities.

  • Military Health System (MHS):

    • Funded by the Department of Defense, MHS provides healthcare for active military and their dependents, primarily through TRICARE.

Managed Care Organizations (MCOs)

  • MCOs deliver comprehensive healthcare through a network of participating providers under specific contractual agreements, influencing a patient's choice in care.

Types of Managed Care Plans

  • Health Maintenance Organizations (HMOs):

    • Requires enrollees to select a primary care provider; restricts coverage for out-of-network care.

  • Preferred Provider Organizations (PPOs):

    • Offers flexibility; provides coverage for out-of-network care but at enhanced costs.

  • Tiered-Network Plans (TNP):

    • Hybrid that offers varying out-of-pocket costs based on the chosen provider tier; encourages in-network use.

Healthcare Financing Structures

Funding Models

  1. Self-Funded Model:

    • Individual or responsible party pays out-of-pocket for medical care; uncommon model.

  2. Bismarck Model:

    • Introduced by Bismarck for German unification, employs an insurance mechanism for comprehensive coverage.

  3. Beveridge Model:

    • UK’s healthcare model where the government serves as the principal payer and owner, controlling costs.

  4. National Health Insurance (NHI) Model:

    • Similar to Canada’s system where the government is the main payer but providers are private.

  5. Hybrid (Bis-Bev) Model:

    • Combination of Bismarck and Beveridge; exhibits features of both systems, characteristic of the US.

U.S. Healthcare Insurance Coverage

  • Medicare (2017 data):

    • 19.3% of the population.

  • Medicaid (2017 data):

    • 17.2% of the population.

  • Private insurance (2017 data):

    • 67.2% of the population.

  • Uninsured (2017 data):

    • 8.8%, indicating 91.2% of the population is covered by some form of insurance.

Financial Aspects of Healthcare

  • Complex interaction of financing function due to multiple insurance arrangements affects costs significantly.

  • Medicare Access and CHIP Reauthorization Act of 2015 (MACRA):

    • Established the Quality Payment Program to incentivize clinicians for quality of care in Medicare.

    • Required the removal of Social Security Numbers from Medicare cards.

Conclusion

  • The United States healthcare system demonstrates considerable diversity in payer and provider structures and coverage models.

  • Key challenges include managing costs and ensuring equitable access to quality care.

  • Regulatory frameworks and managed care approaches aim to streamline and control healthcare expenditure.