1、The Structure and Funding of the U.S. Health Care System,Adapted from a talk by: Richard L. Dressler, M.D., M.P.H. University of Maryland School of Medicine Department of Family and Community Medicine Academic Year 2006-7,Goals of this module,After this module, participants should be able to: Descri
2、be the structure of the US health care system. Describe how the US health care system is funded. Discuss current and future challenges to the structure and funding. Find information regarding the health care system,Is this pertinent to ME?,Survival in “real world” practice “You eat what you kill” Ph
3、ysicians need to understand the various payment and care systems to be able to keep their practices solvent. Ignoring the “business of medicine” can be fatal to medical practices,Is this pertinent to ME?,The Ongoing/Impending Problems “Access”/”Rights”/”Justice”/”Fairness” All have very different me
4、anings to different people. For example, is access to health care a “right”? Is it given by the constitution? Is it a trans-national “human right”? Need to be comfortable fielding a rational response These concepts are beyond the scope of the module, but these terms are used to describe aspects or d
5、eficiencies in our system.,Is this pertinent to ME?,If you care about nothing else Federal & State governments face a nasty bill. Ultimately, scarce tax revenue is allocated for a variety of causes. This tax revenue comes from us, the taxpayers.,A snapshot of some of the problems,Quality of care U.S
6、. residents receive about 50% of care that is recommended1. Is this good? Acceptable? Individual expenditures By 2025, average family premium will EQUAL median income2 This means 50% of Americans will spend EVERY dollar they make on a health insurance policy.,1McGlynn EA, Asch SM, Adams J et al. The
7、 Quality of Health Care Delivered to Adults in the United States. NEngl J Med. 2003;348:2635-2645. 2Sager A, Socolar D. Data brief No. 8: Health costs absorb one-quarter of economic growth, 2000-2005. Boston, MA: Boston University School of Public Health, 2005,A snapshot of some of the problems,Nati
8、onal expenditures 16% of GNP is health care1 25% of economic growth between 2000-20051,1Sager A, Socolar D. Data brief No. 8: Health costs absorb one-quarter of economic growth, 2000-2005. Boston, MA: Boston University School of Public Health, 2005,Leading Causes of Premature Deaths,McGinnis JM et a
9、l. The case for more active policy attention to health promotion. Health Affairs 2002:21(2);78-93. Project Hope,Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291:1238-1245.,Actual Causes of US Death - 2000,Leading causes of death,How do
10、physicians address these causes? Do you expand office hours to see all of these patients? Maybe thinking outside of the one-to-one” clinical encounter is appropriate? Why or why not?,“The health care System”? What it DOES,One Perspective Provides services: Somatic medical, dental Mental Health couns
11、eling “Complementary/Alternative”,Another Perspective Primary Care: disease PREVENTION & health promotion Vaccine administration, prenatal care Secondary Care: disease DETECTION Breast cancer, hypertension Tertiary Care: disease TREATMENT Pneumonia, major depression,The health care System 5 Main Com
12、ponents,Education and Research: professional schools Suppliers : drugs, equipment Insurers: Government (Medicare, Medicaid, CHIP, VA) Commercial, self-insured employers, Blue Cross/Blue Shield (BC/BS) Payers: State agencies, BC/BS, commercial insurers, “self-pay” Providers: (Next slide),Steinwachs,
13、D. The American Health Care System: Introduction to Health Policy (Class Notes, Unpublished). 2002.,The health care System Provider Groups,Preventive Care: Primary Care Providers (PCPs), state/city health departments Primary Care: M.D./D.O., P.A., C.R.N.P Generalist-specialist continuum some special
14、ists provide primary care, some generalists provide advanced services - OB, colonoscopy Sub acute Care Intermediate care, ambulatory surgical centers,Steinwachs, D. The American Health Care System: Introduction to Health Policy (Class Notes, Unpublished). 2002.,The health care System Provider Groups
15、,Acute Care Hospitals, “Urgent Care” Auxiliary Services Lab, pharmacists Rehabilitation Services Home Health Nursing, Nursing Homes Long-Term Care Nursing Home, Assisted living Integrated Care Managed care organizations Complementary/Alternative Medicine,Steinwachs, D. The American Health Care Syste
16、m: Introduction to Health Policy (Class Notes, Unpublished). 2002.,Public Health,health care System,Environmental Health,Biostatistics,Nutrition,Physical Fitness,Pharmacology,“Basic Sciences”,Inpatient Care,Cancer,“Disparities”,?,Relationship of “Public Health” to “health care System”,Health - Conce
17、ptual Framework,U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. Washington, DC: U.S. Government Printing Office, November 2000.,With all that we spend, focus, and train on “health care”, h
18、ow do we address the “health” part?,“Medicaid HMO”,“Individual coverage”,“Uninsured”,“Medicare”,A lot of money is exchanging hands. Who is accountable to the individual?,Health - Conceptual Framework,Kaiser Family Foundation, statehealthfacts.org - “Health Insurance Coverage of the Total Population,
19、 U.S. (2004)” - downloaded May 4, 2006,United States: Health Insurance Coverage of Total Population, U.S. (2004),Kaiser Family Foundation, statehealthfacts.org - “Health Insurance Coverage of the Total Population, U.S. (2004)” - downloaded May 4, 2006,United States: Health Insurance Coverage of Tota
20、l Population, U.S. (2004),Employer-based coverage is the most common type of health insurance provider in the U.S.,This chart is a generalized overview, because there are many exceptions and overlaps: People can be “dually-eligible” - Medicare-Medicaid patients (generally poor, elderly) Federal empl
21、oyees who get government- purchased health care that is technically “employer-based.”,Employer-Based and Individual,53% - Employer-based, 5% individual-purchased Dependants/spouses Government employees included Most will have DIFFERENT plan in 2 years Little incentive to care for individuals long-te
22、rm health since will probably be insured by someone different in near future. Avg. monthly premium geographic variation Single - $150.00 Family - $280.00,“Update on Individual Health Coverage - Updated” (#7133-02), The Henry J. Kaiser Family Foundation, Aug 2004,Employer-Based and Individual,Tax pol
23、icy favors employee-based benefit Companies that spend money in employee health benefits have incentive. They do not pay tax on the “profit” of the money spent on health care benefits. “Adverse selection” People who know they are sick are more likely to buy health insurance. Makes insuring difficult
24、 Leads individually-purchased health care to be MUCH more expensive than what an individual would pay for a “group rating” employer based health care.,“Update on Individual Health Coverage - Updated” (#7133-02), The Henry J. Kaiser Family Foundation, Aug 2004,Medicare “Elderly”,42 Million recipients
25、 $325 Billion in 2003 Federally-funded 65 years old if “qualified” Disabled or in need of hemodialysis and eligible for social security 13% of Federal budget,“Medicare at a Glance,” (#1066-08), The Henry J. Kaiser Family Foundation, Sept 2005,Medicare “Elderly”,Parts A, B, C, D A: Hospital and Skill
26、ed nursing care B: Outpatient, Physician visits when medically necessary C: “Medicare Advantage” plans, approved by Medicare but run by private companies. Provides A, B & D benefits. D: Drug plan. Voluntary and not automatic. Future: rising health care costs + aging population = situation for concer
27、n.,“Medicare at a Glance,” (#1066-08), The Henry J. Kaiser Family Foundation, Sept 2005,“Medicare at a Glance,” (#1066-08), The Henry J. Kaiser Family Foundation, Sept 2005,“Medicare at a Glance,” (#1066-08), The Henry J. Kaiser Family Foundation, Sept 2005,Increasing elderly population, decreasing
28、numbers of workers to support them.,Medicaid “Poor”,52 million recipients - $266 Billion in 2003 Federal-State Partnership Eligibility varies by State. Generally poor + children, parents of dependent children, pregnant women, disabled “Dual eligible” with Medicare chronically ill, long-term care Cov
29、ers most clinical services + Rx,“The Medicaid Program at a Glance,” (#7235), The Henry J. Kaiser Family Foundation, Jan 2005,Medicaid “Poor”,May contract as “Medicaid HMO” with non-government entity Future more cost limiting. Possibilities: Prescription drug limits Utilization review: evaluate servi
30、ces for medical necessity Prior review and authorization for referrals,“The Medicaid Program at a Glance,” (#7235), The Henry J. Kaiser Family Foundation, Jan 2005,“The Medicaid Program at a Glance,” (#7235), The Henry J. Kaiser Family Foundation, Jan 2005,The Uninsured,Over 45 million in 2004 Cover
31、age = services. No coverage = no services. “But cant they just buy insurance?” ? Employer size as predictor Large firm 98% offer coverage, small firm 59% 8/10 come from working families Price sensitive to premiums AND utilization When price goes up, people decreasingly use that resource. People get
32、sicker and sicker before their medical problems are addressed.,“The Uninsured and Their Access to Health Care,” (#1420-05), The Henry J. Kaiser Family Foundation, Dec 2003,Most uninsured are in working families, but in jobs without benefits.,“The Uninsured and Their Access to Health Care,” (#1420-05
33、), The Henry J. Kaiser Family Foundation, Dec 2003,31,“The Uninsured and Their Access to Health Care,” (#1420-05), The Henry J. Kaiser Family Foundation, Dec 2003,Usually falls to the government to reimburse the provider, if they get reimbursed at all.,Leads to price sensitivity: The higher the cost
34、, the less likely the service will be utilized.,“The Uninsured and Their Access to Health Care,” (#1420-05), The Henry J. Kaiser Family Foundation, Dec 2003,Anderson GF, Hussey PS, Frogner BK, Waters HR. Health spending in the United States and the rest of the industrialized world. Health Aff (Millw
35、ood ). 2005;24:903-914.,Per Capita Health Spending, 2002,Each year, the US spends roughly 2x the amount on health care as the next most spending country,Summary,Health, itself, is not simply a function of health care, but rather a complex interplay of genetics, behavior, social circumstances, and en
36、vironmental exposure. The structure and function of the U.S. health care system is tremendously complicated, with a myriad of stakeholders advocating policies in their self-interest. Physicians must acknowledge our societys need for them to be leaders and agents for change in this complicated system
37、.,Massachusetts Health Care Reform Plan,Passed April 12, 2006 Aims to provide universal health care coverage to state residents Requires all adults to purchase health insurance Modeled on mandatory auto insurance law Low cost options for health care Commonwealth Care Program Government subsidies pro
38、vided to ensure affordability of insurance. Commonwealth Choice Plans offered by insurance companies, approved by the state, with options for those that dont qualify for Commonwealth Care. MassHealth Expansion of Medicaid to make more children eligible, raise enrollment caps for adults. Employers wi
39、th 11 or more employees required to provide a group health plan and pay a fair share of monthly premiums, or pay yearly contribution per employee to the Health Safety Net Trust Fund.,Looking up Information on the health care system,Different types of Information: BackgroundGray literatureStatisticsR
40、esearch and journal articlesInternational health care resources,Background,Resources that offer descriptive and consumer level information on various health care issues and topics MedlinePlus Health System topics Explanations geared to consumers, links to further information and resources Topics suc
41、h as how to find a doctor, home care, health fraud Medicaid/Medicare official sites Explanations of different servicesKaiserEDU.org From the non-profit Kaiser Family health care policy institute Tutorials covering basics like Medicare/Medicaid Emphasis on growing concerns and issues Also includes to
42、pics like womens health, long term care, childrens insurance,Books,Good for explanations that integrate interdisciplinary factors of the health care system (cultural, medical, historical)BU Electronic and print books Search Amazon, Google Books and check the catalog to see if BU owns the book If BU
43、does not own a book, try the Boston Library Consortium Virtual Catalog or Interlibrary Loan E-book “Understanding Health Policy: a clinical approach”,Gray Literature,A lot of material concerning health care issues can be found outside of traditional scholarly resources like books or research article
44、s.This type of information is often referred to as “gray literature” and is comprised of technical reports, reports from non-profits and government agencies (white papers). Because health care is currently such a prominent and controversial issue, you can expect to find a lot of gray literature abou
45、t health care issues. Gray literature can also lead you to a lot of statistics,Finding Gray Literature,Policy Institutes/Think Tanks:National Health Policy ForumCommonwealth FoundationKaiser Family FoundationInstitute of MedicineGovernmentUS Dept. of Health and Human Services “Reference Collection,“
46、 a wide-ranging set of links to online HHS statistics/databases, glossaries, reports, and more. PortalsDuke Health Policy GatewayIncludes links regarding health industry, coverage, expenditure, and reform,Looking up Statistics US Government,AHRQ: Agency for health care research and qualityIncludes M
47、EPS (Medical Expenditure Panel Survey)health care use, expenditures, sources of payment, and insurance coverage. Includes state informationMassachusetts Health and Human ServicesResearcher page for statistics on state programs and population.NCHS: National Center for Health Statisticshealth care sur
48、veys and health insurance statisticsCDC HEALTH, United States, 2007birth and death rates, infant mortality, life expectancy, morbidity and health status, risk factors, use of ambulatory and inpatient care, health personnel and facilities, financing of health care, health insurance and managed care,
49、and other topics,Looking up Statistics Other sources,Dartmouth Atlas of Health CareMassachusetts Health and Human ServicesResearcher page for statistics on state programs and population.NCHS: National Center for Health Statisticshealth care surveys and health insurance statisticsCDC HEALTH, United States, 2007birth and death rates, infant mortality, life expectancy, morbidity and health status, risk factors, use of ambulatory and inpatient care, health personnel and facilities, financing of health care, health insurance and managed care, and other topics,
