Midterm I Review
Midterm I Review PUBHHMP
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This 8 page Study Guide was uploaded by Julia Scheinman on Wednesday February 11, 2015. The Study Guide belongs to PUBHHMP at Universidad de Granada taught by in Winter2014. Since its upload, it has received 79 views. For similar materials see US & International Healthcare in Public Health at Universidad de Granada.
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Date Created: 02/11/15
MIDTE RM 1 REVIEW Strengths and weaknesses of the US Health Care Svstem Outcomes and expenditures What is a fundamental paradox in US health care 0 We spend more than any other country but we aren39t living longer worse rates of infant mortality and mortality 0 Also the rate at which we are increasing our spending is massive Paradox of excess and deprivation in the US Some have access to incredible services even some they don39t need excessive need from reimbursement methods allow that and extra tests On the other side people who need services do not receive them because they cannot pay for the basic number of services Strengths 1 wide variety of services locations 2 welltrained medical professionals 3 latest technology 4 pharmaceuticals 5 short wait times Weaknesses 1 high cost to the consumer 2 overuse of services and waste 3 inadequate or absence of insurance coverage Health Care Financing What are the most common forms of payment in US Health Care How did each arise What incentives do each create What are the problems with each 1 Out of pocket Discourages people from seeking out necessary preventative services which will be more costly down the road Asymmetric Information the person who is selling something knows more than you do and you are reliant on them physicianinduced demand Problems Unpredictable potentially very high expenditures consumer could not afford and not meeting the needs of physicians and hospitals to be reliably paid Transition To Insurance How did insurance arise Hospital quality improved demand for health services increased 0 Insurance was popularized during the Great Depression 0 Physicians wanted a steady stream of income Employmentbased insurance was an quotaccident of historyquot 0 Price Controls during WWII meant no one could receive a wage increase therefor insurance was offered as a fringe bene t to entice workers 1 Private 0 Physicians wanted to get paid reliably Individual pays a premium to the plan and the plan pays the provider 0 Never became a dominant form 1 Employer based 0 Premium the amount a policy holder you or their sponsor employer pay for a plan eg quot2080quot plan Copayment a set xed amount paid for a service or product eg 30visit and 15drug Coinsurance like a copay but based Deductible the amount you pay before your bene ts begin 1000 2500year People are more likely to put off treatment with high deductible plans 0 Community Rating Insurance payments are equal for all individuals enrolled in a plan 0 Cannot survive in a marketdriven private insurance system 0 Community rating redistributes care in accordance with need rather than ability to pay 0 Experience Rating Insurance payments are based on expected expenditures for each subpopulation enrolled in plan as mentioned in text banked pay less than coal miners ex car insurance Discriminatory Fueled problem of rising costs because people used more services and providers raised prices insurers were controlled by hospitalsphysicians who raised prices The Affordable Care Act favors Community Rating but still allows age smoking as factors because health care is a basic human right and charging people more because they need it is contrary to the purpose of insurance Series of social interventions tried to solve problems but in turn created its own problems requiring further intervention Government sponsored health insurance What are the primary forms of government sponsored health insurance What are the components of each program eligibility coverage etc What problems were each intended to solve MEDICARE social insurance model experience rating was racking up cost of private insurance for elderly Federally sponsored program subsidizing care by privately operated health services Enacted in 1965 65 and older or spouse 1972 extended to younger disabled individuals Nationally Consistent policies in all 50 states Medicaid is not Does not provide comprehensive coverage it39s possible to become more from incurring signi cant medical bills and then becoming eligible for Medicaid aka Spend Down PART A hospital insurance with no premiums Eligibility 65 years old Paid into SSS for at least 10 years 40 quarters Totally and permanently disabled under 65 years old Someone with chronic renal diseases requiring dialysis or transplant PART B physician services Voluntary enrollment Requires a premium based on income Late enrollment penalty Paid for by income taxes and monthly premiums Has deductible and coinsurance aspects in addition to premiums Physician services Physical occupational and speech therapy Preventive care mammograms colonoscopy alcohol use counseling heart disease screening Not covered vision dental Eligibility All eligible for Part A Part C quotMedicare Advantagequot Private insurers manage your part A and B bene ts and potentially Part D Since early 197039s option to receive Medicare bene ts through private plans HMOs Subsidizes premiums for private health plans Bene ciaries limited to providers and facilities offered by a plan Lower out of pocket payments Covers Parts A and B sometimes D Individual plans may offer additional services such as vision and dental Capitated per enrollee amounts for Parts A and B Separate amounts for Part D Average 95 of traditional Medicare feeforservice costs prior to 2003 Why HMOs were thought to provide more ef cient care 2003 expansion of premium subsidies to allow all bene ciaries access Result payments 14 higher than traditional Medicare Part D prescription drugs 2003 prescription drug coverage Voluntary enrollment Monthly premiums that vary by type of coverage selected Coverage offered by 1500 private plans lots of choiceand confusion Coverage Gaps prevent moral hazard people using What they don t necessarily need and cost containment Not covered premiums deductibles copays Overthecounter drugs amp Drugs not included in the plan39s formulary Affordable Care Act is shrinking the donut hole year by year Characteristics of Medicare Population 50 Per capita annual income below 22000 50 Per capita savings below 53000 45 3 chronic conditions MEDICAID public assistance model Enacted in 1965 and by 1970 48 states participated Government sponsored program for the poor Jointly nanced by federal and state governments gt lots of variability State participation is voluntary Eligibility US citizens children and pregnant women adults with dependent children people with severe disabilities poor elderly Coverage to 60M lowincome individuals SCHIP covers children in families with income at or below 200 of poverty line Dually eligible Individuals with Medicare part AB and limited income may receive subsidies to pay Medicare premiums Offers more comprehensive long term care than Medicare At least 50 5076 of cost is matched by federal government by matching is determined by state39s average per capita income If under 150 of poverty line no premiums amp premiums cannot total gt 5 of income Internists are more likely to reject Medicaid patients and appointment wait times are longer New incentive to increase payment for primary care to 100 of Medicare rates Federal government wants to states to allow more people onto their Medicaid enrollment expand coverage to all individuals within 133 of FPL the government will pay 100 of Medicaid expenses for that population for a few years Prior to expansion single adults or married adults with no children were left out of being Medicaid eligible Mandatory physician services inpatient hospital outpatient hospital family planning nursing facilities safety net hospital community health center but not prescription drugs or dental or rehab or eyeglasses 25 states cover up to 250 of FPL for children 35 states cover parents with dependent children up to 100 of FPL Poorer states get more federal coverage they have less money and a higher amount of poor to cover so they are less likely to want to expand Medicaid Pays physicians less than Medicareprivate insurance Financial barriers to health care Describe the types of nancial barriers to health care and their causes Who experiences them Lack of insurance People whose employers decide not to provide health coverage self employed unemployed are left to fend for themselves outside of employer sponsored market Often people without employmentbased are ineligible for Medicaid and Medicare but cannot avoid private insurance premiums 25 year trend in decreasing private insurance coverage in US With Affordable Care Act the number of uninsured is supposed to drop from 51 to 22 million The skyrocketing cost of health insurance ca uses employers to shift the responsibility of cost onto employee The workforce has shifted toward more lowwage parttime nonunionzed service unlikely to provide insurance People who are laid off or leave jobs due to illness may also lose their insurance hard to maintain eligibility for Medicaid 75 of uninsured are actually employed low paying small rms part time other 25 are unemployed and below FPL Underinsurance health insurance with limitations that restrict access to care Categories of underinsurance limits to insurance coverage lack of long term care gaps in Medicare coverage deductibles and copayments Non nancial barriers to health care De nitions and examples of the non nancial barriers to health care Who experiences them Availability t between service capacity and individuals39 requirement orneed Accessibility t between location of providers and location of patients geography underserved population with primary care physician shortage Accommodation t between how resources are organized and individuals39 ability to use the arrangement Affordability individual39s ability to pay for needed services Acceptability t between patients39 valuesattitudes and providers39 vales attitudes and practices Accommodation 175 busy with work or other commitments Availability 84 couldn39t get an appointment soon enough Accessibility 44 took too long to get to the doctor39s of ce or clinic Acceptability 40 Doctor or hospital wouldn39t accept health insurance Access to health care and health outcomes What are some of the consequences of lack of access to health services Who experiences them Access to health care is most simply measured by the number of times a person uses health care services The uninsured suffer worse health outcomes than those with insurance The uninsured are diagnosed later higher rates of hypertension and cervical cancer lower survival rates of breast cancer less frequent preventative care visits suffer higher overall mortality rate increases risk of dying by 25 Medicaid recipients have a level of access intermediate between those without insurance and those with private insurance Medicaid patients have lower rates of immunizations screenings and timeliness of prenatal care Socioeconomic status appears to be the dominant in uence on health status Underinsured were more likely to skip appointments tests and ll prescriptions because costs are too high deaths annually to underinsurance 3500045000 deaths from underinsurance Neighborhoods with African AmericansLatinos have fewer physicians Access problems are ampli ed for African Americans and Latinos because more of them are uninsured or on Medicaid Provider and hospital reimbursement structures Risk Of incurring nancial burden potential to lose money earn less money or spend more time without payment What forms of reimbursement did we discuss in class What are the different aspects of each What incentives do they create Explain the concept of tiers 1 Fee for service Physicians have incentive to perform more services gt rapid rise in healthcare costs The only nonaggregated method Most risk is on the insurer payer Early 199039s Medicare moved to resource based relative value scale 1 Payment by episode of illness DRG in hospital Hospital is paid one sum for all services delivered during one illness Risk to provider to lose shifts portion of risk from payer to the physician and the larger of services the larger the risk shifted Most common for surgeons and OBGYN Incentive to perform more surgeries but limit postopera tive visits Medicare at risk for number of admissions but hospital at risk for duration and resources 1 Per diem payments to hospital Hospital is paid for all services to patient during 1 day Insurer at risk for of days patient stays utilization re vie W and hospital has no incentive to perform expensive procedures 1 Capitation payment One payment is made for each patients care during a month of year Shifts risk from insurer to provider Minor procedures can be carved out and paid FFS Risk adjusted capitation higher monthly payments for chronically ill and elderly Incentives for providers Keep population as healthy as possible have to treat population and get no more money they bene t from keeping you healthy at a lower cost to you Control costs clear population of patients allows clout and exibility for how to best organize and deliver services Policy makers prefer salarycapitation to decrease healthcare costs Usually 3 tiered in US Health Plan gt IPA gt physician but physician income is increased by denying diagnostic and specialty services Hospitals bear all risk and HMO has no risk but has disappeared as payment for to hospital 1 Global budget Payments for all services delivered to all patients within a certain time period issued by HMO that owns the hospital Alternative to per diem and per capita payments Hospital is at risk to gure out to stay within budget 1 Salary Typical in the public sector and community hospitals One payment for all services and patients in a month of a year Employed by hospitals integrated medical groups partnerships Public sector HMOs HMOs may place restrictions on physician practice eg of patients seen Providers may be overworked and not compensated for overtime Trend towards doctor39s being employed by hospitals Private insurers and government wanted to replace FFS with other reimbursement methods to place some economic pressure onto physicianshospitals to limit the number and cost of services rendered Now payment is determined by negotiation of payers and providers instead ofjust providers Manization of Care Primarv Secondarv and Tertiarv care What are the key attributes of primary secondary and tertiary care What are the main models of organizing health care discussed in class What are the strengths and weaknesses of each PRIMARY The provision of integrated accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs developing a sustained partnership with patients and practicing in the context of family and community First contact Longtitudinally Comprehensiveness Care coordination Family physician general interest general pediatrician geriatrician ER physician lst contact for acute care OBGYN lst contact for reproductive care nurse practitioners physician assistants PCP Shortage is getting worse Bene t prevention of diseases via Childhood immunizations Cost adverse effects of vaccines Out of pocket expenses 20 higher for primary care than for specialty care SECONDARY medical care provided by a specialist or facility sometimes upon referral by a primary care physician that requires more specialized knowledge skill or equipment than the primary care physician has More complex health problems than in primary care setting More specialized and narrow Typically provided in hospital setting Acute Care in ER Includes skilled medical attendance Childbirth intensive care medical imaging services Secondary Care Providers Specialists working at the hospital Surgeon radiologist cardiologist Specialists in private practices Orthopedists psychiatrists ENT dentists Allied health professionals in ambulatory settings 0 Physical therapists speech therapists dieticians massage therapist Medical Specialties 0 Can be classi ed into Surgical or internal medicine surgical oncology anesthesiology Age range of patients pediatric surgery internal medicine Diagnostic or therapeutic pathology oncology Organ based or technique based cardiology radiology Tertiary Care rare and complex disorders neurosurgeons thoracic surgeons pediatric hematologists Two Models of Care 1 Regionalized Dawson Model Britain Gatekeeping you must see a primary care provider rst who then will refer to the regional specialized care provider Pro Cost saving by encouraging people to seek primary care rst amp stronger coordination of care Weakness may be inconvenient and people lack freedom of choice 1 Dispersed Model of Health Care US Division of primary secondary and tertiary care but higher value on tertiary care 0 Patients can be referred by general practitioner AND patients can selfrefer Hospitals are less rigidly staffed Diamond shaped rural hospitals don39t have specialized care few elite medical center provide specialized care and most hospitals in the middle provide a wide range of secondary and tertiary care 0 Our emphasis on specialization and technology is compatible with valuesexpectations in US 0 Our overemphasis on tertiary care creates a system where our resources are not well matched to community problems but the ecologic view reminds us we have more needs at the primary level 0 Health care has lost sight of the whole person and community we39re good at rescuing but that doesn39t impact the general population 0 Off balance fragmented lack coordination Factors Driving US Health Care Organization Biomedical Model Academic Medical centers in the early 20th century designed to nd 39magic bullets39 for diseases with quotdiscreteknowabe causesquot physicians were trained to master organ systems Financial Incentives amp Professionalism Insurance rst only covered hospital costs Specialty services were more time consuming when quotfirst introducedquot now more routine yet reimbursements remain high Gap in pay for primary vs secondary physicians is large Government involvement Hill Burton funded hospital construction Medicare and Medicaid higher reimbursements for specialty procedures and extrapayments for teaching hospitals Professionalism physicians highly trusted by US Policy Makers which has had a highly powerful role in shaping the system
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