Healthcare delivery in the US- Barksdale

Question 1

Insuring the autonomy of the patient and having the right to practice medicine.

Answer 1

???

Question 2

What is health policy?

Answer 2

changes that will influence how healthcare is delivered, how much it costs, and who will be affected

Question 3

US healthcare system is

Answer 3

fragmented: public/private insurance provider mix and excessive administration costs

duplicate studies because we don’t have a unified system

Question 4

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?

Answer 4

Under some proposals universal health care would
end private insurance entirely and transform the
U.S. healthcare delivery system.

Question 5

If some national single payer insurance plan would capture what type of persons?

Answer 5

28 million uninsured would get health care insurance coverage.

Question 6

Critical pieces for the insurance reform process?

Answer 6

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

Question 7

In regards to the proposed National Health Insurance legislation, what are the two bills associated with it?

Answer 7

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.

Question 8

What are two of the biggest cost drivers for healthcare labor?

Answer 8

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.

Question 9

2019 opens with drug price increases —charging what the market will bear

Answer 9

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???

Question 10

What is the per capita cost for pharmaceutical and drugs in the US?

Answer 10

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).

Question 11

Why is healthcare cost and delivery unsustainable in the long term?

Answer 11

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.

Question 12

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?

Answer 12

5%

Question 13

What is insurance?

Answer 13

is just a means of accessing healthcare

Question 14

What was the huge outcome for the ACA in 2017?

Answer 14

uninsured came down to 10% from previous 19%

Question 15

What was the driver to making???

Answer 15

34:00???

Question 16

Employer Sponsored Health Insurance

Answer 16

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)

Question 17

Number of Uninsured In the U.S. (among nonelderly population)

Answer 17

However, in 2017, the number of uninsured people increased by nearly 700,000 people, the first increase since implementation of the ACA.

Question 18

Why Do People Remain Uninsured?

Answer 18

-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

Question 19

What is the dominant manner in which healthcare is delivered in the US?

Answer 19

Managed Care Organizations Models

Question 20

What are the type of managed Care Organizations Models?

Answer 20

• 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.

Question 21

What are the top 5 US health insurance payers?

Answer 21

United Health Group

Anthem (formerly Wellpoint-Anthem)

Aetna

Humana

Cigna

Question 22

50 different flavors of the same Medicaid because everys state does it their own way

Answer 22

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

Question 23

What are the four parts of medicare?

Answer 23

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

Question 24

There is an ongoing need to improve physician counseling of individuals on end of life options. Why?

Answer 24

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.

Question 25

Medicaid is under state or federal? What does it cover?

Answer 25

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

Question 26

What is Children’s Health Insurance Program - CHIP?

Answer 26

-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.

Question 27

Why is Medicaid under threat due to the mandatory Work Requirement?

Answer 27

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????

Question 28

What is non-emergency medical transportation, or NEMT?

Answer 28

patients who have to travel afar to get to their hospital appointments why not fund their transportation? Non-emergency medical transportation, or NEMT, is a basic Medicaid benefit. From its inception, in 1966, Medicaid has been required to transport people to and from such medical services as mental health counseling sessions, substance abuse treatment, dialysis, physical therapy, adult day care and visits to specialists.

Question 29

What was Healthcare in America Before the Affordable Care Act?

Answer 29

The sicker you were, the more you payed. • Premiums varied widely for men, women and elderly. • Denial of coverage for pre-existing conditions. • Everyone was not required to carry health insurance. • People paid for plans with very limited benefits. • Lifetime caps for coverage. • Employers were not compelled to offer employees health insurance. • Adults, especially males without children or families, had limited access to Medicaid benefits. • Hospitals bore the full brunt of uncompensated care for the uninsured. • Approximately 45 million people did not have health insurance.

Question 30

Congress eliminated the individual mandate. What does this mean?

Answer 30

there is no tax or penalty for not having health insurance

Question 31

What were the key provision of the Affordable Health Care for America Act?

Answer 31

Insurers through ACA are required to spend at least 80% of premiums on direct medical care and efforts to improve care quality. Mandatory rate reviews prior to requests for premium increases

Question 32

What is the Essential Health Benefit Packages?

Answer 32

help to level the playing field to ensure all insurance offer appropriate provision Essential Health Benefit Packages (coverage that provides for establishing uniform essential health benefits - (EHB). The goal is to limit cost sharing for such coverage, limit the amount of deductibles, and limit total cost of out of pocket spending for the insured… and would include: ambulatory care services, emergency services, hospitalization, maternity and newborn care, rehab and laboratory services, mental health and substance abuse services, prescription drugs, prevention and wellness services and pediatric service

Question 33

What is the wanted goal for medicaid expansion?

Answer 33

will yield more people who are insured At least four more are expected to do so in 2019. Maine approved a ballot initiative in 2017 to expand Medicaid. Utah, Idaho, and Nebraska approved expansion initiatives on their 2018 ballots. In 2018, Virginia lawmakers approved Medicaid expansion, which takes effect in January 2019 (enrollment began in November 2018). New Hampshire, Indiana, Pennsylvania, Alaska, Montana, and Louisiana have expanded their Medicaid programs since 2014.

Question 34

What is the impact of the ACA?

Answer 34

Coverage gains from 2013 to 2016 were particularly large among groups targeted by the ACA, including adults and poor and lowincome individuals. The uninsured rate among nonelderly adults, who are more likely than children to be uninsured, dropped 8.4 percentage points from 20.6% in 2013 to 12.2% in 2016. People of color, who had higher uninsured rates than nonHispanic Whites prior to 2014, had larger coverage gains from 2013 to 2016 than non-Hispanic Whites. Though uninsured rates dropped across all states, they dropped more in states that chose to expand Medicaid, decreasing by 7.2 percentage points from 2013 to 2016 compared to a 6.1 percentage point drop in non-expansion states.

Question 35

What have been attempts to remove the ACA?

Answer 35

Federal Judge Attempts to Strike Down Entire ACA On December 14, 2018—federal district court judge Reed O’Connor issued a decision in Texas v. Azar, a lawsuit challenging the constitutionality of the individual mandate and, with it, the entire Affordable Care Act (ACA). Because the individual mandate is “essential” to and inseverable from the ACA, the judge declares, the entire law is invalid.

Question 36

ACA – 2019 Future Considerations

Answer 36

The 2019 plan year has the potential to be just as uncertain due to major policies including implementation of association health plans and short-term, limited-duration plans.

Question 37

What are Association Health Plans?

Answer 37

An AHP is a type of self-insured multiple employer welfare arrangements (MEWAs) recognized by the Employee Retirement Income Security Act of 1974 (ERISA) - business and employer trade associations—such as chambers of commerce or farm bureaus—which offer group health insurance to their members, which often include self-employed individuals, small businesses, and large businesses. some employer group health plans are exempt from state laws and regulation that govern insurance would not need to meet most requirements of the ACA with regards to benefits, eligibility, or costs

Question 38

Going Forward – Improving ACA

Answer 38

-Prevent the misuse of special enrollment implement stricter rules so people can't wait to sign up until they need care. -Better monitor insurance costs across states -Require all insurers who want to sell in the individual insurance market to offer their plans through the exchange, so they couldn’t cherry-pick individuals outside the exchange -Implement reinsurance -Reimbursement for services should reflect the actual cost of the service (cost containment) -Maintain current healthcare subsidies -Reimbursement for services should reflect the actual cost of the service and should be bundled -Information technology systems need to enable patient centered care. Although this seemed to be the premise of EHRs, in reality, most have focused on enhancing billing, revenue, and documentation, rather than closely tracking the health, wellness, outcomes, and cost of individual patients throughout the care continuum. -Introducing a public plan option in HIX areas lacking individual market competition -Take actions to reduce prescription drug costs, healthcare vs. investment opportunities-one of the highest cost drivers of US healthcare - Reduce the waiting period for those on disability insurance to get Medicare coverage from two years to six months to move some of the very high-cost enrollees out of the individual-market pool Give foreign drug companies, vaccine manufacturers and device makers easier access to our markets,

Question 39

U.S. Hospital Shut-Downs

Answer 39

Hospitals have been closing at a rate of about 30 a year, according to the American Hospital Association (2018), and patients living far from major cities may be left with even fewer hospital choices as insurers push them toward online providers like Teladoc Inc. and clinics such as CVS Health – MinuteClinic or urgent care facilities. The risks are coming in part following years of mergers and acquisitions. Consolidations like Aetna-CVS Health, could also pressure hospitals as payers and push patients toward outpatient services. Rural hospitals with a smaller footprint may have less room to negotiate rates with managed care companies and are often serving more older, poorer and often uninsured patients. “Microhospitals,” or facilities with ten beds or less, are another trend that may hold promise in the marketplace.

Question 40

Free Standing Emergency Departments

Answer 40

-A freestanding emergency department (FSED) is a facility that is structurally separate and distinct from a hospital and provides emergency care. CMS does not allow for Medicare or Medicaid payment for the technical component of services provided by independent freestanding emergency centers (IFECs).

Question 41

Mergers and Acquisitions of pharmaceutical companies

Answer 41

doesn't always translate for better services or cost for patient may move patients to minute clinics as opposed to a real physician (CVS merging with Aetna, aetna encouraging their clients to go to the minute clinic)

Question 42

One of the following describes Health care system in the US

Answer 42

segmented system

Question 43

One of the following does NOT impact Health care in the US?

Answer 43

-high mortality rate in the US decreases healthcare expenditure DOES - high price tag of prescription drugs - chronic illness drains the health care system in the US - patient require aggressive treatment to prolong lifespan

Question 44

According to WHO, the first country on per capita health care expenditure is?

Answer 44

US

Question 45

Healthcare system in which government provides insurance for all residents and pay for all healthcare expenditures is

Answer 45

single payer

Question 46

Healthcare system in which government requires all residents to purchase insurance is called

Answer 46

insurance mandate

Question 47

The first country to implement the single payer system is

Answer 47

Norway

Question 48

US ranks what on infant mortality in 2009? | Infant mortality rate in the US is?

Answer 48

43rd 6.9

Question 49

Approximately 5% of the US population account for what percentage of healthcare expenditure?

Answer 49

30%

Question 50

The percentage of Employee based insurance with health care reform in the United States represents about?

Answer 50

56%

Question 51

Healthcare system in which patients go through a single point of entry is called

Answer 51

managed care

Question 52

One of the health care model in which physicians who care for plan members are employees of the plan is called?

Answer 52

group model

Question 53

Preferred Provider Organizations

Answer 53

beneficiaries who use out of network face higher out of pocket costs

Question 54

Medicare has the following criteria except?

Answer 54

-it is funded mutually by state and federal DOES have: - it is funded by federal alone - include older individuals and persons with disabilities - individuals who suffer from chronic kidney failure are covered - high income does not affect your eligibility

Question 55

Part of Medicare that covers inpatient hospital stays

Answer 55

Part A

Question 56

Medicare Advantage Program

Answer 56

allows beneficiaries . to enroll in health maintenance organizations

Question 57

Approximately 30% of Medicare dollars are spent during

Answer 57

the last 60 days of life (2 months)

Question 58

The largest insurer during the last year of life is?

Answer 58

Medicare

Question 59

The largest insurerer in the United States is?

Answer 59

Medicaid

Question 60

All of the following are true regarding Medicaid except?

Answer 60

-paid for by the federal government only (false) DOES: -paid for by federal and state

Question 61

Children's Health Insurance Program

Answer 61

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 -provides for routine check-ups, immunizations, doctor visits, prescriptions, dental and vision care, inpatient and outpatient hospital care, laboratory and xray services and emergency services

Question 62

Federally supported states-based market place

Answer 62

consumers apply through healthcare.gov Federally-supported State-based Marketplace: States with this type of Marketplace are considered to have a State-based Marketplace, and are responsible for performing all Marketplace functions, except that the state will rely on the Federally-facilitated Marketplace IT platform. Consumers in these states apply for and enroll in coverage through heatlhcare.gov.

Question 63

14 state based marketplaces (13 and DC)

Answer 63

State-based Marketplace: States running a State-based Marketplace are responsible for performing all Marketplace functions. Consumers in these states apply for and enroll in coverage through Marketplace websites established and maintained by the states.

Question 64

Under affordable health care act

Answer 64

insurers are required to spend at least 80% of premiums on medical care

Question 65

Basic Health program

Answer 65

a health benefits coverage program for low-income residents who are not eligible to purchase coverage

Question 66

Concierge medicine

Answer 66

ensures immediate access to a primary care physician

Question 67

Value based healthcare delivery

Answer 67

- patients spend less money to achieve better health - providers acheive efficies and greater patient satisfaction - payer control costs and reduce risks - supplies align prices with patient outcomes

Question 68

Value based healthcare delivery

Answer 68

- patients spend less money to achieve better health - providers achieve efficiency and greater patient satisfaction - payer control costs and reduce risks - supplies align prices with patient outcomes

Question 69

What were the two supreme court challenges on the ACA?

Answer 69

- that is was unconstitutional to mandate people to have an insurance - other challenge was whether states should mandate states to expand their Medicaid program