the u.s. healthcare system an overview of what's what
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The U.S. Healthcare System
• An overview of what’s what
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Stakeholders
• Patients• Employers• Providers• Payers• Government• Accreditors
• Purchasers
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What’s My Aim?
• Patients
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What’s My Aim?
• Patients– Unlimited wants / Access– Effective treatment
• Cure; symptoms; safety
– Efficiency of care– Economy of care– Education; knowledge– Low administrative burden– Respect
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5OUTPUTSOUTPUTSINPUTSINPUTS
Customers
Community NeedPlan to Improve
Vision
Customer Knowledge
Design, Redesign
Suppliers
Process
back
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Number of People, United States 1990 - 2020
0
10,000,000
20,000,000
30,000,000
40,000,000
50,000,000
60,000,000
1990 2000 2010 2020
85 + 65 +
Year
US Census Bureau released 12/23/99; 1/13/2000
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What’s My Aim?
• Employers
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What’s My Aim?
• Employers– Satisfied employees– Contain health care costs– Employee wellness– Profitability of the firm
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What’s My Aim?
• Providers
• Who are?
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Care Providers
• Examples– Pharmacists– Physicians– Physician Assistant– Nurses / Nurse Practitioner– Dentists
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What’s My Aim?
• Providers– Improve health of patients– Autonomy– Authority– Economic viability of the practice– Professional development– Research
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What’s My Aim?
• Payers
– Who are?
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What’s My Aim?
• Payers– Coordination of transactions– Rate setting– Risk assessment and underwriting– Information– Economic viability– Legal / ethical considerations
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Health Insurance in the United States
64% 24%
14%
US Census Bureau Current Population Survey http://www.census.gov/prod/2001pubs/p60-215.pdf
PrivatePrivate
PublicPublic
NoneNone
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Health Insurance in the United States
Uninsured
Medicaid
Medicare
Military
Private Self-purchase
Employer -Based
64%
14%
10%
13%
8%
US Census Bureau Current Population Survey http://www.census.gov/prod/2001pubs/p60-215.pdf
+ Rx Limited Rx Usually No Rx
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Components of the Care Care Premium Payment
HIAA Issue Brief: “Why Do Health Insurance Premiums Rise?” March 2000
Physicians and Physicians and Other Health Other Health
ProvidersProviders
43%43%HospitalsHospitals
32%32%
Drugs and Drugs and Medical SuppliesMedical Supplies
13%13%
Nursing and Nursing and Home Health Home Health
CareCare
2%2%
Claims and Claims and Consumer Consumer ServicesServices
10%10%
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U.S. Health Care Spending
1.9
1.6
1.3
0.9
0.6
0.20.1
0.0
0.5
1.0
1.5
2.0
1970 1980 1990 1995 2000 2005 2008
OverallRx Drugs
year
U.S.Trillion
$
11%5%
National Health Statistics Group, Office of the Actuary, Health Care Financing Administration: National Health Accounts
HIAA Issue Brief: “Why Do Health Insurance Premiums Rise?” March 2000: Source: CMS Data
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What’s My Aim?
Government• Federal
Government• State
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What’s My Aim?
• Government• Federal
– Provide for those whom the market does not serve
– CMS
– Prevention
– Research
– Regulate
• Government• State
– Provide for those whom the market does not serve
– Medicaid– Local programs– Mental health– Elderly– Regulate
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What’s My Aim?
• Accreditors
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What’s My Aim?
• Accreditors– Quality– Audit– Unintended consequences of cost containment– Evidence-based medicine– Credentialing
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Care Settings
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Care Settings
• Community / Ambulatory– Outpatients– Homebound– Assisted Living / Adult Day Care
• Inpatient – Hospital– Institutionalized
• Long-term Care– Nursing Home / Institutionalized
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Primary Care
• Physician– PA, NP
• Settings– Office– Clinic– ED
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Ancillary Care Services
• Pharmacy
• Laboratory
• Radiology
• Physical Therapy
• Alternative Therapies?
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Who Pays?
• Private– Indemnity insurance– Managed care
• HMO, PPO, POS
– Payment• Prospective (capitation)
• Retrospective
– Patient purchased
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Who Pays?
• Public– Medicaid
• FFS, Managed care
– Medicare• Medicare+Choice
– Other• Champus, SCHIP, etc
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Who Manages?
• Trends– Cost inflation
• Technology• Consumer demands / psychology• Market-based system• Prescription drugs• Demographics
– Baby boom
• Chronic disease• Lifestyles
– rationing
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Who Manages?
• Trends– Quality of care
• Satisfaction
• Safety– Error
– Risk
• Efficiency of health care delivery– Reduce waste
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Who Manages?
• Regulation / Accreditation– CMS– QIOs– NCQA– JCAHO– Patients’ Rights– IOM