Chapter 2American Health Care

System

HOSPITALS IN THE USA• 59% of hospitals are non-gov’t, non-profit

• 18% are for profit hospitals

• 23% are specialty hospitals (Will’s Eye, Children’s Hospital, etc

• Ratings by various agencies

• Emergency Rooms (John Hopkins study, 2005) E.R. Directors reported not enough doctors on call, especially for specialties such as hand, neuro, ENT, psychiatry

• US had the most expensive health care system according to certain measures

• Presently 46% of health care is funded by the taxpayers in the form of state, federal, or social security taxes. (black/cash market ?)

Hospital QualityHospitals and Healthcare facilities are accredited by The Joint Commission (TJC)

The TJC develops standards of performance & awards accreditationfor meeting or exceeding those standards

It includes:1. Prof. Review Cmte. comprised of active physicians who evaluateQuality of care at hospitals2. Utilization Cmte.which reviews hospital admissions and length ofstays.3. Audit Cmte.- reviews books for defective or unecessay care4. Tissue Cmte.- reviews surgeries

Discipline of Physicians:

• Hospitals may reduce, suspend, or revoke hospital treatment privileges• Medical Societies may reprimand or expel members• States may revoke or suspend medical licenses to practice in that state.

National Practioner Data Bank (NPDB)- Gov’t requires certain bodies and officials to report certain actions against physicians to this data bank. This is used as a reference in legal, hiring, and insurance matters.

Healthcare Integrity & Protection Data Bank (HIPDB)- Same as above but limited to criminal convictions, civil judgments, malpractice actions, license andcertification actions and exclusion from state/federal healthcare programs.

Federal Gov’t is the primary regulator of health benefits provided by employersCongress established minimum national standards for group health insurance(changed under Obamacare)

COBRA (Consolidated Omnibus Budget Reconcialtion Act) – one can continueHealthcare coverage under certain conditions, such as: termination or lay-offs(You have to pay for the coverage which is expensive).

Universal Healthcare- Types and Arguments

For: • All citizens should have access to affordable healthcare15-17% do not ( Is this true? Who are they?)• US is the only industrialized nation w/o universal healthcare• Freedom to choose health insurer is limited by the state in which you live.

Against:• Is is “socialized” medicine• Supported through heavy taxation and taxes would increase• Long wait periods for tests and surgery• Lose freedom to choose your own physician

Form

er Pro

gra

m

vs.Obam

aca

reFormer System

1. Ins. Premiums

too high

2. Waste

3. Prescription

Med. Mrkting.

4. 15%

uninsured

5. Sick People

Dropped

6. If sick, you

cannot get

insurance

Obamacare

1. Claimed to

reduce

Insurance cost,

opposite effect

2. Website (items

to address

fraud)

3. No change

4. Interest in

program waning

5. Fixed

6. Fixed

Models of Universal Healthcare

National Health Service Model (Great Britain)

• Gov’ts deliver and insure healthcare• Funded by taxes• Gov’t owns/leases buildings, facilities, etc• Doctors, etc are Gov’t employees or independent contractors• Could still have co-pays and deductibles• Still have the option of private insurance(Guess who can afford and does pay for private insurance?)

Issues:-Doctors earn less-Legal liability- who is responsible?-Less admin costs-Less defensive medicine as doctors have less legal liability(less unnecessary tests, labs, which decreases costs-Little cost to the consumer leads to overuse/abuse and greater demand -thus harder to get a doctor surgeon, service etc.

Single Payer Model – (Canada)

>Fewer insurance companies (effect on economy?)>Fee for service model>All fees set by the Gov’t or a board (similar to our Medicare System)>All $$$ paid to the Gov’t who then distributes payments (single payer system)

Issues:>Decreases administrative costs/fraud because it is easier to monitor>Limits the free market in medicine- doctors take what the gov’t pays. >Better doctors do no receive financial rewards.>Increase in taxes to fund it. >Most people have a supplemental private plan (usually through their employer) Everyone must have a Family Doctor who is the gatekeeper and referrals are Required. Surveys indicate vast majority of citizens are satisfied with their system Wait times can be long

Insurance Exchanges (Obamacare)• States encouraged through federal aid ($$$) for developing insurance exchanges.• These are markets offering a menu of insurance plans• This provides for more options and competition in the insurance marketplace• States can run the exchanges or pay a company to do so, or the feds

• If the state doesn’t comply the feds may run the exchange. • If an individual is not covered by an employer plan, they are encouraged to enroll in the exchange. This is paid by the individual.

• Idea is to get all people to enroll thus lowering cost of health insurance as more• healthy people ( will not need the service) will enroll.

• If you do not enroll, you will have to pay a penalty to the IRS.• Insurance Companies must cover all people regardless of health and cannot drop them if they get sick. This increases costs which raises premiums of insurance policies.

• Some doctors and hospitals have opted out of participation in these exchanges and networks.

• Plans that do not meet the plans minimum standards have been cancelled.

Obamacare- tech glitches, administered by a friend of the First Lady.

Selecting a Hospital:

Which physicians have admitting privileges to that hospital?Which healthcare insurance plans cover that hospital?Ratings: US News and World ReportConsumer’s Checkbook

Types of Senior Living Facilities

Retirement Communities- low level of service, primarily for independentSeniors

Assisted Living- those that need help with activities of daily living (bath, dress,grooming, etc) They coordinate health services, medications, therapy, transportation, etc. Some have specialized units such as Alzheimer’s, Dementia, etc

Nursing Homes/Skilled Nursing Facilities

Have R.N.s, M.D. supervision, custodial care such as bath, toilet, in/out of bed

ISSUES with all of these:

Costs-LTC insuranceMedicare FacilitiesAlways visit before choosing. (Questions on p. 42)