12 - 1 introduction to us health care text by dennis d. pointer, stephen j. williams, stephen l....

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

12 - 4

Ensuring Quality

Policy Based Upon…

• Medical Research?

•Cost Reimbursement?

Care Provided…

• PCP thinks is appropriate?•Administrators think is appropriate?

12 - 5

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

12 - 6

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

12 - 7

Managed Care Features

• Utilization Review• Provider

Networks• Preventative

Care• Reduction of

Paperwork*• Copayments• Gatekeeper

• Comprehensive preventative care – cost effective

12 - 8

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

12 - 9

Managed Care Features

• Utilization Reviews• Provider Networks• Preventative Care• Reduction of

Paperwork*

•Copayments• Gatekeeper

• Flat fee at time of service

12 - 10

Managed Care Features

• Utilization Reviews• Provider Networks• Preventative Care• Reduction of

Paperwork*• Coypayments

•Gatekeeper

• Members must have referral from PCP to see specialist

12 - 11

Managed Care Organizations

• Health Maintenance Organizations (HMOs)

• Preferred Provider Organizations (PPOs)

• Point-Of-Service (POS) Plans

12 - 12

Managed Care Organizations

•Health Maintenance Organizations (HMOs)– Links together a health plan,

hospitals, and physicians into a network

12 - 13

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

12 - 14

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)

12 - 15

Assessing Performance

• Impact on quality and cost• Impact on physicians and health care

providers

13 - 16

Introduction to US Health Care

Chapter 13

Promoting Health and Preventing Disease

13 - 17

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

13 - 18

The Effect on Governing Boards

• Economic dynamics

• Burgeoning health care systems

• Higher expectations of accountability

13 - 19

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

13 - 20

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

13 - 21

Incremental Change…

• Limiting federal government health care expenditures

• Making health insurance plans more accountable and patient-friendly

13 - 22

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???

13 - 23

Potential Reconfigurations

• Increase age limits• Increase taxes and

contributions• Limit coverage• Restrict benefits• Increase coinsurance

and deductibles• Reduce payments

13 - 24

Aging and Demand For Services

• Changes in lifestyle• Biomedical and

pharmacological technologies

• The way health care is provided

• Financing priorities

Short-Term Care

13 - 25

Aging and Demand For Services

• An increase of chronic disease

• Disappearance of nearby extended family

Long-Term Care

13 - 26

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

13 - 27

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…

13 - 28

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

14-30

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

14-31

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

14-33

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

14-39

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