Health Care Systems; Definitions

Remove disease causing agents from the environment; treats populations

Direct intervention to detect or or prevent (e.g., screening); patient is ambulatory

initial diagnosis and treatment; daily, routine needs; patient is ambulatory; point at which the patient enters the health care system (e.g., a cold)

More specialized; more serious problems; ambulatory or overnight hospitalization (e.g., back surgery)

Very specialized; most serious problems; complex care; almost always overnight in hospital (e.g., serious cancer operation)

Is defined by the patient- feel good, then a significant change for the worse, then seek out help

Is defined by the professional- a pathological process

Is a social status conferred by others- they agree someone is sick, should not be blamed, should be exempt from normal tasks, and should try to get better and use the professional system

Is complete well being- an ideal to strive for; can try to prevent/detect as well as treat disease

Government grants permission to engage in an occupation or use a certain title; usually requires exam (e.g., Pharmacist)

Qualified individual listed on an official roster maintained by a governmental or nongovernmental agency (e.g., RPh; MT[ASCP])

Nongovernmental agency grants recognition to an individual that possesses certain qualifications (e.g., Board Certified Physician or Pharmacist). Testing may be required.

Nongovernmental agency gives stamp of approval to health care institution (e.g., JCAHO and hospitals) or health professions education program (e.g., ACPE and colleges of Pharmacy)

Various services provided by various professionals in various settings to those with temporary or permanent functional disabilities of a physical or mental origin, intended to promote or maintain functional independence- not to cure

Health insurance is protection against the costs of hospital and medical care arising from illness or injury (plays a big role in shopping for health care because in addition to being essential and expensive, health care is uncertain)

Rating is a continuum with community on one end and experience on the other (it's how insurance companies decide which group of people will serve as the basis when deciding a premium); can be either community rating or experience rating

In pure form, community rating might be when a single premium is calculated for everyone in the United States based on average expected utilization.

In pure form, experience rating might be when a premium is calculated for each individual based on their health and utilization history.

The amount the insured has to pay for covered services before benefits become active (e.g., a yearly cost)

Insured has to pay a percent of the reimbursement (e.g., 20%)

A flat amount the insured has to pay for each utilization event (e.g., $5 per prescription)

Patient pays provider, and insurer reimburses patient (shoebox effect)

Insurer pays provider directly

Periodic payment required to keep policy in effect

A fixed amount of money (flat payment) paid to a physician per patient per unit time, regardless of whether the patient is ill or well;

it is a system of payment based on the physician's patients, rather than the services provided to each patient. (Pure (simplified) example: Doctor gets paid $X per year for treating #X amount of patients, no matter what services provided)

-HMOs combine financing & delivery

-A pure HMO owns its own hospitals and pays its physicians a salary

-Contractual arrangements (capitation) are often used to foster the incentives created by a pure HMO

-Benefits are usually comprehensive, and cost-sharing minimal

-Grew out of the “fee-for-service” system

-Preferred provider gives discount to insurer when patient uses that provider

-Patient cost-sharing lower if preferred provider used

-Grew out of the HMO system

-Patients wanted more choice

-If patient leaves network, cost-sharing is higher

Managed care in the most general sense means "overseeing the physician's decisions; managed care does not equate with putting the provider at economic risk.

Characteristics include:

-Primary care physician as gatekeeper (responsible for ALL primary care, refers to specialists, oversee and coordinates care)

-Utilization oversight (prospective or retrospective, prior authorization, second opinion)

-Networks (more potential for management control)

-Consumer controls (waiting times, case management, self-care)

• 1- Diseases of the heart
• 2- Malignant neoplasms (cancer)
• 3- Cerebrovascular diseases (e.g., stroke)
• 4- Diabetes
• 5- Chronic lower respiratory diseases (e.g., COPD)
• 6- Accidents
• 7- Alzheimers
• 8- Influenza and Pneumonia

2.3 trillion total

16.2%

$7,681 per capita (U.S. population is approximately 302 million)

• Hospitals= 31%
• Physicians and clinical= 21%
• Drugs= 10%
• Nursing homes= 6%
• Administration= 7%
• Other= 25%

(Other very large due to redefinition of the categories)

Overall health spending grew from 4.4-7% (from 2007)

Uninsured= 44 million in 2009; this is about 15% (U.S. census bureau NCHC)

Underinsured= 25 million in 2007

• - 11% of those with incomes < $40k
• - 31% of those with incomes < $20k

- Biology (genetics, aging, internal systems)

- Environment (physical, social, psychological)

- Lifestyle (consumption, leisure, employment)

- Health system (preventive, curative, restorative

They:

• - Have a perceived need
• - Go to the "lay system" for help
• - Adopt the sick role
• - Enter the professional system
• - Are diagnosed; physician decides
• - Are treated (therapy); physician decides

(There are outcomes of the process)

1) Governing Board (Board of trustees or directors)

2) Administrator or Chief Executive Officer (CEO)

3) Medical Staff

- More intensive nursing care than ICF

- Bridges the gap between hospital and home

- Shorter term than ICF

- Medicare and Medicaid pay

- Less intensive nursing care than SNF

- More custodial care

- Longer term than SNF

- Medicaid and self-pay dominate

- Medicare: 19%

- Medicaid/SCHIP: 15%

- Other public (e.g. VA): 12%

- Private insurance: 35%

- Out-of-pocket: 12%

- Other private (e.g. in-plant): 7%

(Medicare and Medicaid = about 1/3; Public = almost ½)

- Financed by payroll taxes

- Mainly for hospitals and skilled nursing facilities, home health, and hospice

- Has deductible per benefit period

- ICF not covered

- Hospital deductible per benefit period: $1100

- Hospital co-payments per benefit period: $275/day for the 61st- 90th day, and $550/day for the 91st-150th day

- Skilled nursing facility co-payments: up to $137.50/day for the 21st-100th day

- Uses PPS (prospective payment system) as a payment system

- Financed by premiums and general revenue

- Mainly for physicians and outpatient lab tests, x-rays, etc.

- Has premium, deductible, and co-insurance

- Voluntary

- Premium: $96.40/month (may be higher depending on your income)

- Deductible: $155/year

- Co-insurance rate: 20%

- Uses RBRVS (resource-based relative value scales) as a payment system

The HMO and Medicare + Choice programs are now considered together as Medicare Advantage.

- Medicare enrollees can choose to join a Medicare-approved HMO if there is one in their area. If so, the government pays the HMO a premium, and the HMO takes responsibility for the patient’s care. Patient still pays Part B premium. Cannot be charged more than Part B premium.

- Medicare HMOs must cover at least what traditional Medicare covers and often cover more to attract patients. HMO was only option.

- Later, the Balanced Budget Act (BBA) of 1997 created Medicare + Choice (was called Part C)

-- Allows enrollees to select other, more loosely defined managed care and other options in place of traditional Medicare. (PPO and FFS plans-not just HMO)

-- Under this approach, which is intended to give enrollees more choices and foster competition, plans can charge enrollees premiums beyond the Part B premium. Benefits can vary, too.

- This complicates decision-making for the elderly.

•Medicare Prescription Drug, Improvement and Modernization Act was passed into law in November 2003.

•New law includes a voluntary outpatient prescription drug benefit that took effect in January, 2006 = Medicare Part D.

Eligibility:

• - All Medicare beneficiaries
• - Benefit is voluntary
• - Monthly premium average is in the $12-$32 range (could be $0 – could be much more)
• - Government pays additional amount to plan
• --------------------------------------------------------------
• - Drug benefits are provided through private plans, which will bear the risk

- Plans are chosen by the beneficiary and must provide coverage that is actuarially equivalent to the standard coverage

- dollar value of coverage under a Part D plan is equal in dollar value under another plan is equal to dollar value of standard plan

- 2 different ways to do it:

• - Traditional Medicare plan with an add on stand-alone Rx drug plan (PDP)
• Medicare Advantage Plans (e.g. PPO, HMO)

Standard coverage in 2009:

•benzodiazepines; fertility drugs; drugs for anorexia, weight loss or gain; cosmetic or hair growth drugs; symptomatic relief of cough and colds; most prescription vitamins or minerals; OTCs; barbiturates

(other than classes NOT covered, at least two drugs in each therapeutic class or category based on USP standards)

- antidepressants

- antipsychotics

- anticonvulsants

- antiretrovirals

- immunosuppressants

- antineoplastics