Health care delivery in the U.S.
is unlike other developed countries
�Is delivered by an array of providers in a
variety of settings
�Is paid for in a variety of ways
�Is U.S. health care a "system?
Access to Health Care
�Insurance coverage and generosity of coverage are major determinants of access to health care
�2011 - 46.3 million uninsured (15.1%); 58.7 million uninsured for part of the year (19.2%)
�Likelihood of being uninsured greater for those: young, less educat
Quality of Health Care
Quality health care should be:
�Effective �Safe �Timely �Patient centered �Equitable �Efficient
�Groups that measure quality: AHRQ, NCQA
The Cost of and Paying for Health Care
In 2014, projected health expenditures: $3.1 trillion
�U.S. biggest spender on health care in the world by total spent
�Payments come from four sources:
�Direct or out-of-pocket payments
�Third-party payments from private insurance, governmental insurance
Reimbursement
payments made by the third-party payers to providers
Fee-for-service
a method of paying for health care in which after the service is rendered, a fee is paid.
Packaged pricing
several related health services are included in one price
Resource-based relative value scale (RBRVS)
reimbursement to physicians according to the relative value of the service provided
Capitation
a method of paying for covered health care services on a per-person premium basis for a specific time period prior to the service being rendered
Prospective reimbursement
uses pre-established criteria to determine in advance the amount of reimbursement
the cost of and paying for health care
out of pocket payment 10.2%
federal government 42.6%
other third party payers 15.4%
private health insurance 31.9%
Health Insurance
�A risk and cost-spreading process, like other insurance
�Cost is shared by all in the group
�Generally "equitable," but increased risk may
lead to increased cost
policy
is written agreement between a private insurance company(or the government) and an individual or group of individuals to pay for certain health care costs
Premiums
periodic payments (a set amount of money)
Deductible
the amount of expenses that the beneficiary must incur before the insurance company begins to pay for covered services
Co-insurance
the portion of the insurance company approved amounts for covered services that a beneficiary is responsible for paying
Co payment
a negotiated set amount that a patient pays for certain services
Fixed indemnity
the maximum amount an insurer will pay for a certain service
Exclusion
a health condition written into health insurance policy indicating what is not covered by the policy
Pre-existing condition
a medical condition that had been diagnosed or treated usually within the 6 months before the date a health insurance policy goes into effect
Types of Health Insurance Coverage
Dental
Disability
Hospitalization
Long term care
Major medical
Optical
regular medical
surgical
Self-Funded Insurance Programs
�Programs created for/by employers rather than using commercial insurance carriers
�Many benefits to the employer
�Generally for larger companies, unless low-risk employees
Medicare
�Covers more than 48 million people �Federal health insurance program for those:
�65+, permanent kidney failure, certain disabilities
�SSA handles enrollment �Contributory program through FICA tax �Four parts
�Hospital insurance (Part A), medical insuranc
Medicaid
�Health insurance program for low-income; no age requirement
�53+ million covered by Medicaid
�Eligibility determined by each state; very costly budget item for states
�Noncontributory program
CHIP Children Health Insurance program
�Created in 1997 for 10 years
�Reauthorized in 2009 through 2013
�Funding assisted by increase in federal excise tax rate on tobacco
�Targets low-income children ineligible for Medicaid
�State/federal program
Supplemental Health Insurance
Help cover out-of-pocket costs not covered through primary insurance
�Medigap �Other supplemental insurance �Long-term care insurance
�Preserve financial assets, prevent need for family or friends to provide care, enable people to stay independent longer,
Managed Care
�Goal to control costs by controlling health care utilization
�Managed by MCOs �Have agreements with providers to offer
services at reduced cost
�Common features - provider panels, limited choice, gatekeeping, risk sharing, quality management and utilizat
Types of Managed Care
�Preferred provider organization (PPO) �Exclusive provider organization (EPO) �Health maintenance organization (HMO)
�Closed-panel HMO �Open-panel HMO �Mixed model HMO �Staff model HMO �Independent practice associations (IPAs
National health insurance
�A system in which the federal government assumes responsibility for health care costs of entire population; primarily paid for with tax dollars
�U.S. only developed country without national health care plan
�Seven failed attempts at national health care
Consumer-directed health plans (CDHPs)
�Consumer responsibility for health care decisions with tax-sheltered accounts
�Health savings accounts �Flexible spending accounts �Medical Savings Accounts
Affordable Care Act
the president Obama passed the law to help american citizen have affordable health insurance.