12 - 1 introduction to us health care text by dennis d. pointer, stephen j. williams, stephen l....
TRANSCRIPT
12 - 1
Introduction to US Health Care
• Text by
Dennis D. Pointer, Stephen J. Williams, Stephen L. Isaacs &
James R. Knickman with Tracy Barr
• PowerPoints by Robin Pickering Eastern Washington University
12 - 2
Introduction to US Health Care
Chapter 12
Managed Care
12 - 3
Controlling Costs
Controlling Access• Referrals• Type of care• Specify provider Controlling
Price
• Negotiate fees with in-network providers
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Ensuring Quality
Policy Based Upon…
• Medical Research?
•Cost Reimbursement?
Care Provided…
• PCP thinks is appropriate?•Administrators think is appropriate?
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Managed Care Features
• Utilization Reviews
• Provider Networks
• Preventative Care• Reduction of
Paperwork*• Copayments• Gatekeeper
• Patients required to get approval from the organization before receiving certain services
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Managed Care Features
• Utilization Reviews
• Provider Networks
• Preventative Care• Reduction of
Paperwork*• Copayments• Gatekeeper
•Patients must use specific providers who have contracts with the organization
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Managed Care Features
• Utilization Review• Provider
Networks• Preventative
Care• Reduction of
Paperwork*• Copayments• Gatekeeper
• Comprehensive preventative care – cost effective
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Managed Care Features
• Utilization Reviews
• Provider Networks
• Preventive Care• Reduction of
Paperwork*• Copayments• Gatekeeper
• Members do not fill out claim forms
•Increased paperwork for providers
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Managed Care Features
• Utilization Reviews• Provider Networks• Preventative Care• Reduction of
Paperwork*
•Copayments• Gatekeeper
• Flat fee at time of service
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Managed Care Features
• Utilization Reviews• Provider Networks• Preventative Care• Reduction of
Paperwork*• Coypayments
•Gatekeeper
• Members must have referral from PCP to see specialist
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Managed Care Organizations
• Health Maintenance Organizations (HMOs)
• Preferred Provider Organizations (PPOs)
• Point-Of-Service (POS) Plans
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Managed Care Organizations
•Health Maintenance Organizations (HMOs)– Links together a health plan,
hospitals, and physicians into a network
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Managed Care Organizations
•Preferred Provider Organizations (PPOs)– Similar to HMOs, but do not PCP as
gatekeepers– Tend to require greater out-of-
pocket payments from members
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Managed Care Organizations
•Point-Of-Service (POS) Plans– Combination of HMO and POS
(choose each time)– Encourage use of gatekeeper– Choose out of network provider
(with penalty)
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Assessing Performance
• Impact on quality and cost• Impact on physicians and health care
providers
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Introduction to US Health Care
Chapter 13
Promoting Health and Preventing Disease
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U.S. Health Care System
• Growing in complexity– Advances in
medical science and technology
– Evolving understanding of the human body
– Increase in demand for treatment
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The Effect on Governing Boards
• Economic dynamics
• Burgeoning health care systems
• Higher expectations of accountability
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Challenges Facing Health Systems
• Complex and unwieldy organizations
• Cost reductions have not been realized
• Huge losses in various investments
• Integration of systems has been problematic
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Financing Health Care
Health Care Costs
Number of Insured
•Growing number of uninsured
•Enter system sicker =
boost in cost
•General inflation
•Increased medical expense
•Increasing population
•Increase in demand
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Incremental Change…
• Limiting federal government health care expenditures
• Making health insurance plans more accountable and patient-friendly
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Funding Medicare
• Largest health plan and payer of hospital and physician services
• Rising costs and increasing population create major problem
• Bankrupt? Reconfigure Medicare?
What Goes In = What Comes Out???
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Potential Reconfigurations
• Increase age limits• Increase taxes and
contributions• Limit coverage• Restrict benefits• Increase coinsurance
and deductibles• Reduce payments
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Aging and Demand For Services
• Changes in lifestyle• Biomedical and
pharmacological technologies
• The way health care is provided
• Financing priorities
Short-Term Care
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Aging and Demand For Services
• An increase of chronic disease
• Disappearance of nearby extended family
Long-Term Care
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Challenges for Primary Care
• The “cult” of specialization
• Too few generalists, too many specialists
• The impact of managed care
• Lack of government direction
• Changing medical models
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The Underserved Populations
• Increasing diversity in the workforce• Changing education• Changing reimbursement strategies• Changing federal and state programs• Relying on the impact of managed
care
Fixing the Problem…
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Other Challenges…
• Advancing technology• Shortage of nurses• Evolving public health threats• Declining financial health of hospitals
Introduction to US Health Care
Chapter 14
Public Health Policy
14-29
Public Health Services
Protection of the nation’s public health is a government responsibility.
Public Health Agencies Three core
functions are
Assessment
Policy Developm
ent
Assurance
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The Department of Health & Human Services (DHHS)
The DHHS and various federal agencies perform several public health functions.
•Data gathering and analysis, and surveillance and control: The CDC
•Conducting and sponsoring research: The NIH
•Providing programmatic assistance to state and local governments
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The Department of Health & Human Services (DHHS)
The DHHS and various federal agencies perform several public health functions.
•Ensuring the safety of food and drugs: The FDA
•Ensuring access to health services by aged and poor
people: The CMS
•Providing direct services to special populations14-32
State Health Agencies
The state’s role in public health:
Licensing health care
professionals
Inspecting and licensing
health care facilities
Collecting vital statistics
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The state’s role in public health (contd.)
Investigating and analyzing the epidemiology of disease
Epidemiology study includes three factors:
1.Incidence
2.Distribution
3.Control14-34
The state’s role in public health (contd.)
• Observing and managing communicable diseases in the
community
• Registering diseases and tumor information
• Providing laboratory services
• Formulating health policy and legislation
• Analyzing health policy and legislation’s impact
• Providing community health education
14-35
• Food safety inspection• Sanitation services• Investigation and control
of STDs• Drinking water purification
Local Health Agencies
Most front-line public health services are provided locally.
14-36
Private Health Care Providers
Private health care providers contribute to the public health by:
• Engaging in surveillance and monitoring of diseases
• Administering immunizations• Screening for communicable diseases• Offering patient education• Coordinating the provision of private
and public health services14-37
Researchers conduct surveys comparing the U.S. population to populations in other developed countries. Key indicators are:
Cost Access Responsiveness Infant mortality Fairness of financing
Health Indicators
14-38
To classify health systems researchers look at a number of factors.
Degree of primary care regulationType of financial access to health careWhether the health system relies on generalists or
specialists to provide primary care
Characteristics of the Health System
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To determine if a the foundation of a country’s health system is primary or specialty care researchers look at the following factors:
Extent to which the PCP acts as the point of entry into the system Extent to which the physician provides continuous care over time Comprehensiveness of the care provided Extent of coordination of services by the PCP
Primary Care or Specialty Care
14-40