Characteristics of Managed Care
-seeks to achieve efficiency by integrating the basic functions of health care delivery
-employs mechanisms to control utilization of medical services
-determines the price at which the services are purchased and how much providers get paid
The financing of a managed care organization is primarily based on...
Capitation
What is Capitation?
A payment mechanism in which all health care services are included under one set fee per covered individual.
What is Medicare?
Medicare is a U.S. government program focused primarily on the elderly
Why is the U.S. healthcare system considered to be imperfect?
Prices are determined by health plans rather than the interaction of the forces of supply and demand
What is the most dominant health care delivery system in the U.S. today?
Managed care
What is the major role of the U.S. government in the US health care delivery system?
To be a major financier of health care delivery for both Medicaid and Medicare
In a socialized health insurance system, health care is financed through
government-mandated contributions by employers and employees
In a free market...
...buyers and providers act independently
The social justice system emphasizes
community over the individual
What is medicaid?
Government program for the poor
Parties that act as key players in the US Health Care System
Large employers, government, and physicians
What is the primary reason for employers to purchase insurance plans to provide health benefits to their employees?
The U.S. does not have a universal health care system so employers purchase health insurance plans to fringe benefit for their employers.
How is the tax-supported national health care program in a national health care insurance system financed?
...
What is national health insurance?
a tax-supported mechanism in which the government guarantees basic package of health services to all citizens
Over the last decade, the hallmark of the US health care industry has been?
organizational integration to form integrated delivery systems or networks
America's safety net is for
the nation's vulnerable positions
The military medical care system is free for who?
active military personnel
Vulnerable populations
Poor, uninsured, and people of minority status
Result of growth in science and technology
More demand for new services
What is the social justice principle?
Emphasis is placed more on the well-being of the community over the inidividual
The United States spend more than any other developed country on health care, and costs have
continued to rise
Health care managers are needed to
manage and coordinate various types of health services
Main players in the private managed care sector
Licensed health maintenance organizations (HMOs) & preferred provider organizations (PPOs)
Role of MCOs (Managed Care Organizations)
Integration of health care components; Example: paying providers through capitation per head arrangement
Four key functions of managed care delivery
Financing, insurance, delivery, and payment
What is TriCare?
a program financed by the U.S. Department of Defense, which permits beneficiaries of military personnel to receive care from both private and military medical facilities.
The VA system
organized into 21 geographically distributed Veteran's Integrated Service Networks (VISNs)
Veterans Integrated Service Networks
Responsible for coordinating the activities of the hospitals and other facilities located within jurisdiction.
What is an IDS
A network of health care providers and organizations that provides or arranges to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the clinical outcomes and health status
The most important principles in delivering integrated care that us specific to vulnerable populations
An emphasis on primary care, coordination of all care (including behavioral, social, and public health services), and accountability for population health outcomes.
Long-term care
medical and non medical care that are provided to individuals who have chronic health issues and disabilities that prevent them from doing regular daily tasks; Medicare does NOT cover this; Medicaid covers several different levels of LTC services but pers
Mission of the public health system
To improve and protect community health
ACA provisions for public health care efforts
Established Prevention and Public Health Fund to provide expanded and sustained national investments in prevention and public health, to improve health outcomes, and to enhance health care equality
Main characteristics of the U.S. Health Care System
-No central governing agency and little integration and coordination
-Technology-driven delivery system focusing on acute care
-High in cost, unequal in access, and average in outcome
-Delivery of health care under imperfect market conditions
-Government
Advantages of having a centrally controlled health care system
They are less complex and less costly; Global budgets are used to control total expenditures and govern availability and utilization of services.
Technology Driven and Focus on Acute Care
When technology and research increases, consumers and patients demand innovative and sophisticated care. Consequently, finances for such care shrink at much faster rate. Not enough emphasis is placed on public health and primary care which produce better
High in Cost, Unequal in Access, and Average in Outcome
Even though the U.S. spends almost 17% of GDP on health care , many residents have unequal access.
Who in the U.S. has access to health care services when needed?
Those with health insurance through their employers, those who are covered under a government-sponsored health care program, those who can afford to buy insurance out of their own private funds, and those that are able to pay for service privately or can
Imperfect Market Conditions
Health care in the U.S. is only partially governed by free market forces; described as being quasi-market; prices set by agencies external to the market and payer is MCO, Medicare, or Medicaid.
Perfect Market Conditions
Multiple patients and providers act independently; providers would be chosen based on price and quality of services; supply & demand