Healthcare delivery in the US- Barksdale Flashcards
Insuring the autonomy of the patient and having the right to practice medicine.
???
What is health policy?
changes that will influence how healthcare is delivered, how much it costs, and who will be affected
US healthcare system is
fragmented: public/private insurance provider mix and excessive administration costs
duplicate studies because we don’t have a unified system
Medicare for All - which would create a singlepayer health plan run by the government and
increase federal spending by at least $2.5 trillion a
year, according to preliminary estimates to as
much as $32.5 trillion over ten years.
An essential but deeply controversial issue at the
heart of the single-payer model — would people
lose the choices offered by private insurance?
Under some proposals universal health care would
end private insurance entirely and transform the
U.S. healthcare delivery system.
If some national single payer insurance plan would capture what type of persons?
28 million uninsured would get health care insurance coverage.
Critical pieces for the insurance reform process?
Drug company profits would likely fall as the government
would have more bargaining power to negotiate lower
prices. (there has to be control of drug prices)
Health insurance companies as we now know them - would
mostly be eliminated (CVS and Aetna merged in November 2018 and CEO walked out with the a lot of money (500 million)–what did they do to get that???
Doctors and hospitals would likely face pay cuts, but would
no longer face unpaid bills so they may be winners in the
long run
In regards to the proposed National Health Insurance legislation, what are the two bills associated with it?
House version
The Expanded and Improved
Medicare for All Act legislation pending in the U.S. House of
Representatives.
A bill introduced by Senator Bernie Sanders (I-VT) S. 1804 Medicare
for All Act (2017). The bill would expand Medicare into a universal
health insurance program.
What are two of the biggest cost drivers for healthcare labor?
Prices of labor and goods, including pharmaceuticals and administrative costs are
major drivers of the difference in overall cost between the United States and other high income countries.
2019 opens with drug price increases —charging what the market will bear
typically the pricing is greater than the cost of inflation in a given period
-3 dozen drugmakers have raised prices on more than 250 prescription drugs
Novartis and Pfizer will raise their prices but not right now???
What is the per capita cost for pharmaceutical and drugs in the US?
Per-capita spending on pharmaceuticals was $1,443 in the US
Administrative costs alone accounted for 8% of GDP in the US, compared to 1%-3% in the other countries.
Doctors and nurses made more money in the US than in
the other countries, with non-specialist physicians (GPs)
getting salaries of about $218,000, compared to an average of about $123,000 for eight other countries in the
Organization for Economic and Cooperative Development -
OECD study (2016).
Why is healthcare cost and delivery unsustainable in the long term?
NHE grew 5.8% in 2015, $3.2 trillion or $9,990 per
person, and accounted for 17.8% of GDP, the estimate
is $5.7 trillion (20% of GDP) by 2026, if not sooner.
Approximately what percentage of the U.S. population is frail and chronically ill and account for nearly half of all health care expenditures in a given
year?
5%
What is insurance?
is just a means of accessing healthcare
What was the huge outcome for the ACA in 2017?
uninsured came down to 10% from previous 19%
What was the driver to making???
34:00???
Employer Sponsored Health Insurance
it is still something that benefits employers (to have insurance for their workers)
there’s push to put burden on the employees
Employers are:
-increased employee co-payments (26 percent)
– increased their employee’s share of the premium (25 percent)
– implemented a health care plan with a deductible of $1,000 or
more (22 percent)
– reduced the number of health insurance plans they offer (19
percent)
– eliminated coverage for spouses and partners (12 percent)
Number of Uninsured In the U.S. (among nonelderly population)
However, in 2017, the number of uninsured people increased by nearly 700,000 people, the first increase since implementation of the ACA.
Why Do People Remain Uninsured?
-cost is the big driver
-45% of uninsured adults said that they remained
uninsured because the cost of coverage was too high-even
with ACA access.
-Some people who are eligible for financial assistance under
the ACA may not know they can get help, and undocumented immigrants (10-12 million) are ineligible for Medicaid or ACA Marketplace
coverage.
-making too much money to qualify for Medicaid but not enough to buy their own insurance
What is the dominant manner in which healthcare is delivered in the US?
Managed Care Organizations Models
What are the type of managed Care Organizations Models?
• Staff or Group Model – (HMO): a type of managed care plan in which the plan
has contracted with a multispecialty physician group to care for plan
members; a type of managed care plan in which physicians who care for plan
members are employees of the plan.
• Independent Practice Association (IPA): a type of managed care plan which
contracts with many physicians or physicians groups in an area to provide care to plan members.
• Exclusive Provide Organizations (EPO): Managed care plans that provide
benedicts to subscribers who are required to use this group of network providers exclusively for care.
• Preferred Provider Organization (PPO): a large group of hospitals and
physicians under contract to a managed care plan. Health care providers in the
PPO serve plan members for negotiated fees and copayments. Plan members
who use providers not in the PPO (network) face higher out of pocket costs.
• Point of Service (POS) you can use out of network managed care providers, but
at a much higher cost.
What are the top 5 US health insurance payers?
United Health Group
Anthem (formerly Wellpoint-Anthem)
Aetna
Humana
Cigna
50 different flavors of the same Medicaid because everys state does it their own way
Medicare-the exclusively federal program that pays for health services for individuals 65 or older or people with severe and permanent disabilities and Medicaid-a
federal/state cost-sharing program, that pays for
certain health services for persons who meet
certain eligibility criteria as determined by the
states
Medicare would be easier to for all than medicaid that’s why it is being discussed
What are the four parts of medicare?
Part A: covers inpatient hospital stays, skilled nursing
facility stays, home health visits
Part B: covers physician visits, outpatient services,
preventive services, and home health visits
Part C: medicare advantage
Part D: prescription drug benefit
There is an ongoing need to improve physician counseling of individuals on end of life options. Why?
Approximately 30% of traditional Medicare dollars are
spent during the last year of life and half of that is spent
during the last 60 days of life, much of that spent on
futile care that may have prolonged patient suffering.
Medicaid is under state or federal? What does it cover?
both state and federal
- maternity care
- Nearly half of all births in the country.
- 60% of nursing home and other long-term care expenses.
- More than one-quarter of all spending on mental health services and over a fifth of all spending on substance abuse treatment.
covers 40% of poor nonelderly adults. Medicaid
covers 60% of children with disabilities and 30% of nonelderly adults with disabilities
What is Children’s Health Insurance Program - CHIP?
-provides a safety for America’s children
-It provides coverage to children in families who
earn too much to qualify for Medicaid but not enough to afford private insurance.
-In some states, CHIP covers pregnant women.
Why is Medicaid under threat due to the mandatory Work Requirement?
in order to qualify for medicaid benefits you had to work or provide evidence of seeking work
they may be provided a waiver 57:00????
