Unit II Flashcards
Why are physicians less likely to accept Medicaid patients than Medicare patients?
Lower reimbursement rates for the same services (~34% less)
Lawrence P. Casalino, MD, PhD
NEJM on why physicians should care for a reasonable number (5%) of Medicaid patients:
core professional principle that physicians should put patient’s interest first
-refusing to care for vulnerable, socioeconomically disadvantage = incompatible with principle
NFIB vs. Sibelius
Court ruling that required Medicaid expansion in all 50 states was unconstitutional, effectively making expansion optional
- only 31 states plus DC have expanded so far
- individual mandates (and penalties) constitutional under General Tax clause
What type of plan do most people in the US have?
Private, employment-based
What type of government plan do most people in the US have?
Medicaid
Where does a majority of the nations $3.0 trillion in health come from?
Health insurance
1) Private health insurance
2) Medicare
3) Medicaid
4) Out of pocket
Who are the big five?
1) United Healthcare
2) Anthem
3) Aetna
4) Humana
5) Cigna
What is Insurance?
An approach to managing risk and uncertainty
- pay a small amount in advance to protect against larger amount later
Who is the financial risk of those who are insured distributed amongst?
The insured population
What are insurance companies in the business of?
1) Accepting risk for a price
2) Setting rates based on magnitude of risk among individuals and communities they insure
What is the basic business model of health insurance?
Insurance companies:
1) collect premiums from beneficiaries
2) pay claims from premiums
3) after admin costs, rest is profit
What can insurance companies determine or work to influence (4)?
1) Size of premiums
2) cost-sharing: how much claims they pay for directly (cost-sharing)
3) negotiations/discounts: which providers they accept claims from and how much they pay/reimburse them
4) kinds of claims that are reimbursable/covered
What two types of ratings are used to shape premiums?
1) Experience rating
2) Community rating
Experience rating
Use how much an individual or group spent on care in the past to determine individual or group premium
Community rating
Use geography, family composition (sometimes age, gender) to set premiums
Why are premiums set based on risk ratings?
likelihood of magnitude, types, and costs of care not uniform across population
When/how did health insurance begin in the US?
1929: provided a hospital insurance plan for public school teachers in Dallas at Baylor university
- 1200 teachers enrolled, $.50/month/21 days of hospital care
What is Blue Cross’ insurance model?
1) Fixed monthly fee from enrollees
2) Hospitals agree to provide care (prepaid plan)
What is Blue Cross’ model based on?
Hospital care
-Began in 1933, endorsed by American Hospital Association, as nonprofit
What is Blue Shield’s model based on?
Physician Services
- 1939
- endorsed by: AMA
What is the significance of Blue Cross and Blue Shield on the national health insurance efforts?
Physicians maintained control = deterrent
Key Moment in Private Health insurance: 1942
Wage freezes imposed during WWII, employers could offer benefits (i.e. health insurance) in place of wage increases
2016 consequence of 1942 wage freezes
Job lock: individual market out-of-reach for many without employer-based insurance options
Key Moment in Private
Health Insurance: 1954
IRS rules that employment-based health coverage not subject to taxes
2015 consequence of IRS exemption of employment-based health coverage
- ~$250 billion tax subsidy (favoring the wealthy)
- over purchase of insurance
- overconsumption of health care
How were premiums calculated for most of the history of private health insurance in US (until late 1980s)?
Fee-for-service (indemnity) plans
Why did managed care become popular in the 1970s to early 1980’s?
Costs were soaring and there were no mechanisms to control it
Managed care
Organized approach to delivering a comprehensive array of health care services to a group of enrolled members through efficient management of services needed by the members and negotiation of prices or payment arrangements with providers.
What are the primary strategies of cost-control for managed care programs (6)?
1) Choice restrictions
2) Gatekeeping
3) Case management
4) Disease management
5) Pharmaceutical management
6) Utilization review
What are examples of choice restrictions as an approach to controlling costs?
employed/salaried physicians, care networks
Gatekeeping
Cost-control mechanism by which a single provider is responsible for providing referrals to a patient before a patient can access other sources of care
Case management
Separate health care provider coordinates care for patients with complex and costly conditions
Disease management
special outreach for beneficiaries with chronic conditions
What are examples of pharmaceutical management as a mechanism to control costs?
formularies, tiered cost-sharing
What are the types of utilization review?
Prospective, concurrent, retrospective
What are three reasons why the cost of health care rises?
1) Growth in technology
2) Aging poplin
3) Increasing public expectations
What has been the trend in private health insurance?
Managed care has become increasingly popular, while FFS has decreased dramatically
What is Kaiser’s health plan model?
Prepaid group plan; capitation model
Why did Kaiser hire its own staff and build it own facilities?
AMA opposition
HMO (4)
1) Tight coordination and control of health care services; PCP = gatekeeper
2) Very narrow network of providers (no out-of-coverage for patients)
3) Salaried providers; capitated rate per patient negotiated with employers
4) Generally lowest costs to patients amongst managed care options
HMO Act of 1973
Federal law that encouraged the establishment and growth of HMOs by providing federal subsidies, quality standards, and required HMO option to be available to employees
What happened to HMOs in the 1980s/1990s (3) ?
1) Massive growth
2) Move to for-profit
3) new models for provider relationships
Why was there backlash in the 1990s over HMOs?
Patient concerns over quality of care, access to providers, utilization controls
Around what years did the percent of covered employees enrolled in HMOs peak?
1996-2000
What is Yale Health an example of?
Staff model HMO
What is a Staff model HMO?
Physicians are salaried employees of HMO who only see HMO patients; PCP = gatekeeper to specialist
What is a PPO (4) ?
1) Insurer contracts with groups of physicians and hospitals; receives discounts for care provided “in-network”
2) Patients can receive care outside of network (usu higher cost sharing = deterrent)
3) PCP gatekeeping = less common
4) Cost more than HMOs to enrollees; insurers have less ability to control costs
What is a POS Plan?
A hybrid of HMO and PPO
- like HMO: tight provider network, capitation, gatekeeper
- like PPO: some out of network services available; higher cost caring; some gatekeeping
What is the current ranking of popularity of the types of managed care plans?
1) PPO
2) HMO
3) POS
What are the main distinguishing factors amongst the main types of managed care plans?
1) choice of provider
2) delivery of services
3) payment and risk sharing
HMO
choice of provider, delivery of services, payment and risk sharing
1) In-network only w/ salaried/contracted staff
2) Gatekeeping
3)
- Payment: Providers mostly paid capitation, some FFS
- Risk sharing: with providers under capitation
PPO
choice of provider, delivery of services, payment and risk sharing
1) In-network and out-of-network, contracted providers only
2) No Gatekeeping
3)
- Payment: discounted fee schedules
- Risk sharing: none
POS
choice of provider, delivery of services, payment and risk sharing
1) In-network + out-of-network, contracted providers only
2) Limited/no gatekeeping
3)
- Payment: capitation + FFS
- Risk sharing: some
What is the high-deductible health plan also called?
Consumer Directed Health Plans
High-Deductible health plan
High deductible and coinsurance, often used in conjunction with HSAs (with tax advantages)
For high-deductible health plans, who has more financial risk compared to other Managed care options?
The enrollees
What do supporters of HDHPs purport is a benefit of this type of managed care?
“Skin in the game” = promotes greater personal responsibility over health care expenditures
What do critics of HDHPs purport is a negative of this type of managed care?
Wealthier, healthier people more likely to choose this option = rest of insurance pool poorer, sicker (–> higher premiums over time)
Of those enrolled in Medicare Advantage, what is the ranking of managed care plans?
1) HMO
2) Local PPO
3) Regional PPO
What are the three main problems with private health insurance in the managed -care era at the time the ACA was passed?
1) For insured: managed care plans deny necessary care, provide lower care, wide variety in cost of insurance + types of coverage
2) For those w/o employment-based insurance: private insurance unaffordable
3) Widespread provider dissatisfaction with how managed-care reqs affect ability to deliver kind of care they would like.
What are the three main activities of the Department of Veterans Affairs?
1) Healthcare
2) Benefits (GI Bill - Education, Pensions/Compensations)
3) Cemeteries
What is the VA model?
VA healthcare owns and operates health care facilities (inpatient & outpatient), employs clinical and administrative staff
- largest healthcare delivery system in the country
What type of integration is the VA system and example of?
Vertical
How is VA healthcare different from Medicare and Medicaid?
It is not an entitlement program; meeting eligibility criteria alone doesn’t guarantee benefits
How is the budget for VA Healthcare determined?
annual Congressional budget appropriations; up to VA to decide how to allocate money each year amongst three main functions
What are priority groups (VA healthcare)?
8 priority groups used to organize which groups of veterans are enrolled before others
Who is typically in the highest tier of priority groups for VA healthcare and what is the ranking based on?
Those with significant service-related disabilities.
Disabilities are based on “Disability Ratings Schedules”
Who is typically in the middle tier of priority groups for VA healthcare and what is the ranking based on?
Medicaid-eligible, low-income veterans
Who is typically in the lowest tier of priority groups for VA healthcare and what is the ranking based on?
Incomes above thresholds
OR
Minimal/no service-related disability
Note: copays for this group
What is the general consensus for cost sharing for VA healthcare?
1) None for most vets, service-connected injures (highest tier), below income thresholds
2) Lowest priority required to pay co-pay
What is the quality of VA healthcare?
Favorable compared with care in non-VA facilities; high patient satisfaction
Why are there access issues in the VA system?
Eligibility/priority policies given budget constraints
What is the access like for vets with VA healthcare benefits?
Long waits for outpatient appointments; difficulty scheduling within ‘desired date’ target of patient/provider
VA Choice Program
veterans can receive care outside of the VA if:
1) Wait time for appt exceeds 30 days beyond desired date
OR
2) Veteran lives more than 40 miles from nearest VA
- Approved by Congress (2014)
- implementation slow
- long-term future uncertain
- Congress looking for more privatization
VA Secretary Robert McDonald - May 2016
Appointment days not important; veteran satisfaction is better measure.
Compares waiting in line at Disney to waiting to see doctor
What are the three main options to address the uncertain future of the VA Health Care System?
1) Increase funding to expand current system
2) New approaches to redirect more/all VA funding to private healthcare providers/facilities
3) Refocusing VA facilities and personnel to subset services more closely related to service-related conditions
Tricare
- DoD Defense Health Agency for seven uniformed services
- ~9.5 million beneficiaries
- Entitlement program: $52 billion annual spending (10% DoD budget)
Who handles the day-to-day management of Tricare?
Government contractors (large private health insurers)
What does Tricare resemble?
Medicare Part C/ Private insurance program
Who is the main private insurer for Tricare?
Was United Healthcare; now Humana and Centene Corp
Tricare for Life
Medigap-style plan for eligible retired veterans who are also Medicare eligible
Given criticisms that the “Federal health system [is] currently a fragmented patchwork,” what are the (5) opportunities for coordination?
1) Transportation
2) Duplicate payments
3) Facilities
4) IT systems
5) Value-based purchasing
Who owns the Indian Health Service?
Dept of Health and Human Services
How many people have access to Indian Health Service benefits?
~1.5 million out of ~2.2 million AIAN
How does Indian Health Service operate?
- 49 hospitals
- 364 health centers
- contracts with private providers in underserved/difficult to access areas
What is the annual budget of Indian Health Service?
~$4.6 billion
- not an entitlement program; payer of last resort
- CHRONICALLY UNDERFUNDED
Why was Indian Health Service created?
Established in 1802 and formally agreed to in 1832 as partial compensation for land seizures
Snyder Act (1921)
Funds “for relief of distress and conservation of health…[and] fro the employment of physicians…for Indian tribes throughout US”
Indian Self-Determination and Education Assistance Act of 1975
Tribal authorities can assume responsibility for providing health services (IHS grants/contracts)
Indian Healthcare Improvement Act
Permanent as part of ACA (2010)
1931/ Herbert Hoover: Argument in Favor of Health Care Reform
Modern medicine can be brought within reach of persons of average means
- Committee on the Cost of Medical Care
1931/ Herbert Hoover: Argument Opposed to Health Care Reform
Medical soviets…such plans will mean the destruction of private practice.
- American Medical Association
1934-38/ Franklin Roosevelt: Argument in Favor of Health Care Reform
A comprehensive program designed to increase and improve medical service for the entire poplin
- Committee to Coordinate Health and Welfare Activities
1934-38/ FDR: Argument Opposed to Health Care Reform
Opposition to all forms of state medicine.
-AMA
If we have socialized medicine in America…standards of medical practice will degenerate…and patients will suffer.
-NMA
1948/Harry Truman: Argument in Favor of Health Care Reform
A system of Government prepayment health insurance to provide universal access to hospital and physician care.
-Ewing Report
1965/ LBJ: Argument in Favor of Health Care Reform
To improve health care for the American people, [I propose] hospital insurance for the aged under social security.
-President Johnson
1993/ Bill Clinton: Argument in Favor of Health Care Reform
We must make this our most urgent priority: giving every American health security, health care that can never be taken away.
-President Clinton
2010/ Barack Obama: Argument in Favor of Health Care Reform
We have now just enshrined the core principle that everybody should have some basic security when it comes to their health care.
-President Obama
1948/ Harry Truman: Argument Opposed to Health Care Reform
Nations that embark on such programs move inevitably onto a socialized state in which…practically all public services become nationalized.
-AMA
1965/ Lyndon Johnson: Argument Opposed to Health Care Reform
The President’s proposal would be the first step toward establishment of socialized medicine in the US
-AMA
1993/ Bill Clinton: Argument Opposed to Health Care Reform
New government bureaucracies will cap how much the country can spend on all health care
-“Harry and Louise” TV Ads, sponsored by the the Health Insurance Association of America
2010/ Barack Obama: Argument Opposed to Health Care Reform
A major toward socialism and an aggressive government takeover of the health care system
- Congressional Republicans
4 Major reasons why ACA succeeded
1) Major topic during campaign and president willing to spend time and ‘political capital’ on it early in his Administration
2) Large democratic majorities in US Congress facilitated passage (somewhat)
3) Modifies existing structures, but doesn’t reinvent health care financing and delivery
4) Engagement (& deals!) between White House and special interests who might oppose reform
What four special interests had deals with ACA?
1) Hospitals (AHA)
2) Physicians (AMA)
3) Pharmaceutical Manufactuers (PhRMA)
4) senior citizens (AARP)
- no deal with insurers (AHIP) but influence seen in final law
What was the ACA forecast of effects when it was signed?
1) 32 million (of 51 million uninsured) receive insurance coverage from expansion of Medicaid + PHI
2) Total estimated costs over first 10 yrs: $938 billion
- from Medicaid expansion + subsidies
- would reduce federal budget deficit by $124 billion over 10 years
Who is responsible for translating the ACA into practice?
DHHS (and its agencies) = rule making
Rulemaking
translating the language of law into specific policies and practices
What was the impetus for the individual mandate?
Adverse selection
What is the origin of the Individual Mandate?
- Conservative proposal 1990s
- Mitt Romney Massachusetts 2007
Employer mandate
Employers with more than 50 FTE employees must OFFER health insurance to all full-time employees and their families
Plan requirements offered by Employer Mandate
1) Must pass “minimum value” test
2) Must pass “affordability test”
3) Includes “essential health benefits”
Minimum Value Test
covers 60% of costs - equal to bronze plan on exchange
Affordability Test
lowest cost option cannot exceed 9.5% of an employee’s household income
New Requirements for Private Insurance Plans - Pt 1 (3)
1) cannot deny on basis of pre-existing conditions
- “modified community rating”
2) Children/dependents up to 26
3) Muse provide minimum essential coverage, as determined by state policies
Modified community rating
Premium rates based on age, family composition, location, and tobacco use
Mandated Essential Health Benefits under ACA
1) Ambulatory patient services
2) Emergency services
3) Hospitalization
4) Maternity & Newborn care
5) Mental health and substance use disorder services, incl. behavioral health tx
6) Prescription drugs
7) Rehabilitative and habilitative services and devices
8) Lab services
9) Preventive and wellness services and chronic disease management
10) Pediatric services, incl. oral and vision care
New Requirements for Private Insurance Plans - Pt 2 (3)
1) No annual or lifetime limits on insurance benefits
2) Ceiling on annual out-of-pocket costs
3) Minimum percentage of premiums must be used to pay for medical expenses
- rebates to customers if insurers pay less in claims in a given period
Medical loss ratio
Minimum percentage of premiums collected must be used to pay for medical expenses
85% for large group plans
80% for small group plans
Why were the exchanged created?
Because of the individual mandate; needed new mechanisms to facilitate access to affordable health insurance
Exchange (in theory)
Mechanism to pool risk of individuals who are not otherwise part of an insurance pool - creates a new market for insurance
Exchange (in practice)
A government or non-profit entity that collects, organizes, and regulates insurance choices for individuals in a given area
What are the Health Insurance Exchange Plan features (3)?
1) HMO, PPO, POS
2) Different physician networks and other features of managed care
3) Different premiums and cost-sharing structures (within Federal requirements)
What are the 4 types of state health insurance marketplace types?
1) Federally-facilitated marketplace
2) State-partnership Marketplace
3) State-based Marketplace
4) Federally supported state-based Marketplace
Benchmark plan
A plan ID’d by the federal government among those offered in a state’s exchange that other plans must match or have superior coverage to
What are the insurance options organized by?
Tiers that correspond to the average amount of health care costs they cover (“actuarial value”) vs. costs left to the patient
Bronze plan
60%
Silver plan
70%
Gold Plan
80%
Platinum
90%
How are the percentages for each tier obtained?
Through a mix of premiums, deductibles, co-pays, coinsurance
Subsidies
Government-paid discounts available to individual/family plans purchased through exchange, both for premiums and, for lower-income groups, cost-sharing
Public Option
Government-organized health insurance plan that would compete against health insurers for business on the exchanges
What do supporters of the public option argue?
1) Government would have greater leverage to negotiate prices
2) would ensure at least one option available in places where private insurers have withdrawn
What do critics of the public option argue?
1) Government would have greater (unfair) leverage to negotiate prices compared to other insurers
2) government would be regulating insurance market and participating in it
Who is part of the 30-34 million uninsured in 2015 ?
1) 15-17 million likely eligible
2) Uninsured with income too high for ACA or ineligible due to employer coverage offer
3) Uninsured poor adults in non expansion states
4) Uninsured undocumented immigrants
How do you fall in the coverage gap of the ACA?
Medicaid non-expansion state adult between 44% FPL and 100% FPL
Top 4 States with highest distributions of adults in coverage gap
1) TX
2) FL
3) GA
4) NC
How has the ACA affected cost?
Slowdown in rate of increase of national healthcare spending since 2010. Slowest growth in 50 yrs, according to HHS.
- Reasons unknown
- Continued increase in premiums
How has the ACA affected quality?
Too early; small pilot programs + early stages of implementation
2015: King v. Burwell
Premium subsidies available to individuals on exchanges are available regardless of whether the exchange they use is one established by their state or is run by the federal gov’t
What are the three main structures of National Health Care Systems?
1) National Health System
2) National Health Insurance
3) Socialized Health Insurance
National Health System
Financed by gov’t; care provided by gov’t employees (or contractors)
e.g. England
National Health Insurance
Financed by gov’t; care provided by private practitioners
e.g. Canada
Socialized Health Insurance
Financed by (mandatory) contributions from employers/employees; care provided by private practitioners
e.g. Germany
Name 3 analogues of the National Health System in the US
1) VA health
2) Indian Health Service
3) Tricare
Name an analog of National Health Insurance in the US
Medicare
Name an analog of Social Health Insurance
Employer-based health insurance (if insurers were all non-profit)
Sir William Beveridge
Economist and social reformer.
1942: Social Insurance and Allied Services
- all of working age should pay national insurance contribution to provide benefits to sick, unemployeds, retired = welfare state concept
When was the NHS (England) established?
1948
NICE (1999)
set standards for adoption of new technologies and management of conditions
- independent; officially only advisory to NHS but advice almost always followed
- required to consider both clinical effectiveness and cost effectiveness in evaluation of new technologies using QALY
What is NICE (England) comparable to in the US?
Patient-Centered Outcomes Research Institute (PCORI)
How is the British Model funded?
General Taxes
Who controls the funding from General Taxes for the British Model?
National Health Service
How does the National Health Services pay for its Hospitals, Specialist Physicians, and PCPs?
1) Global budget for hospitals
2) Salary for specialists
3) Capitation for PCP
What are the roles of the Central Government in the English National Health Service?
1) Set policies and priorities; manage overall budget
2) Determine covered services
3) Distribute funds to regional health authorities to manage
Clinical Commissioning Groups
England; manage delivery of care in assigned geographical areas
What is a general overview of Canada’s health system?
Principally a financing mechanism for health services: collection of 13 single-payer systems
Who sets the policies, negotiates fees, and handles reimbursements in the Canadian model?
Provinces/territories
How is the Canadian Model funded?
General Taxes
Where do the general funds go for the Canadian Model?
Provincial health plan
How do Provincial health plans in the Canadian health plan allocate funding?
1) Global budget to hospitals
2) FFS to specialists and PCPs
Saskatchewan: 1946 Hospital Services Plan
compulsory, universal hospital care system; other provinces followed
5 Principles of the Canada Health Act, 1984
1) Comprehensive: all necessary health services covered, incl. hospital and physician services
2) Universality: Everyone entitled to same level of care
3) Public Administration: led by public authority on non-profit basis; accountable/transparent
4) Portability: People still covered if they move to another province
5) Accessibility: No unfair additional financial barriers for insured; reasonable compensation for providers
How do Private Health Insurance and National Health Insurance interact in Canada?
Private insurance can only complement national health insurance; illegal to pay privately for covered services, cannot bill patients directly
What are the major issues for the Canada Health System (2)?
1) Waiting times between referral to specialist and eventual tx
2) end of year slowdowns as funds run out
Other countries with National Health Services
Denmark
Finland
Iceland
Norway
Sweden
Portugal
Spain
Other countries with National Health Insurance
Australia
Ireland
New Zealand
Italy
Otto von Bismarck
1883: Established first healthcare system in the world; viewed as useful to maintaining working class support and building a stronger nation
What are other names for the Bismarck model?
Sickness insurance; old-age insurance
-emphasis on solidarity
Sickness Funds
Mandatory funding pooled from employee earnings and employer payments used to pay for healthcare in the German system even if people retire, lose job, or stop working
Who allocates sickness funds?
Concerted action at the regional level
How does the regional level allocated sickness funds?
1) Regulate rates to hospitals
2) Expenditure caps on physician associations
Additional characteristics of sickness funds (3)
1) No exclusions/experience rating permitted; must cover essential services
2) Sickness funds negotiate contracts with provider groups
3) No gatekeepers for GPs
4) Some cost-sharing permitted (mainly co-pays)
In the German Health Care system, how are non-hospital physicians paid?
Through regional physicians’ associations - global sum each year & paid according to fee schedule
In the German Health Care system, how are hospitals and hospital-based physicians paid?
DRGs; salaried.
Other Countries with Social Health Insurance
Austria
Luxembourg
Switzerland
What is the core principle of Chinese Health Care System?
Every citizen entitled to basic health services; love gov’t responsible for providing them according to local circumstances - “modest but comprehensive”
What are the main types of insurance in China?
1) Urban employment-based: employer and employee payroll tax
2) Urban resident and rural populations: government funded
Ongoing challenges in China - Blumenthal and Hsaio (NEJM)
1) Inequalities: poor, rural vs wealthy, urban
2) resistance to reform among profit-driven hospitals, even when publicly owned
3) Difficulty creating high-quality, professional, trusted health care workforce
Indian Health Care System: “Right to health” goal
Universal access to good-quality health care without financial hardship
Indian health care system in principle
coverage of health services universal, available to all citizens under tax-financier system
Indian health care system in practice
Private care sought due to delays associated with government system
What are three ongoing challenges of the Indian health care system?
1) Significant access and outcome inequalities between states, rural/urban, socioeconomic groups, castes, and genders
2) Affordability
3) Wide variability in quality and competence of health care providers and facilities
Scott and Jha
Need to redouble efforts related to safety, effectiveness, and patient-centeredness (middle to low-income countries)
Generalizable lessons from China (Blumenthal and Hsaio)
1) Limitations of reliance on markets in health care systems
2) Value of community health workers and primary care
3) Importance of creating a culture of medical professionalism in driving health care delivery
Generalizable lessons from Developing Countries (Berwick, elsewhere)
1) Patient-centered care, often with prominent role for CHWs
2) less about volume; more about value
3) Benefits of setting clear aims, working collaboratively, expanding programs in stages
Who is the policy-making body of the WHO?
World Health Assembly
Who is the WHO Director-General?
Dr. Margaret Chan
What is the organizational structure of WHO?
1) Six regions - substantial autonomy
2) Regional directors chosen by member countries within each region
3) Limited central WHO authority of priorities, spending, governance
WHO and Health Policy
1) Global disease surveillance and reporting
2) ID and respond to public health emergencies (substantial limitations rel. staff, expertise, resources)
3) Very limited: national health systems/policy at a general level
Who funds WHO’s $4 billion budget?
1) Small fraction from member nation dues - unrestricted funds
2) large fraction voluntary donations from gov’t, NGOs, and other groups – linked to donors’ preferred programs/priorities
UNICEF
Children’s health - vaccination, infant mortality
UNAIDS
HIV/AIDS research and programs
World Bank
Provides financial assistance to developing countries
What are the three increasing areas of focus in terms of the health-related projects of the World Bank?
1) Human capital
2) Reform of health delivery systems
3) Nutrition Programs
Gates Foundation
Largest private foundation in world ($40 billion)
Focus on technological approaches to addressing health concerns and rigorous evaluation of project outcomes
Harvey V. Fineberg, MD, PhD
Author of the Paradox of Disease Prevention - Celebrated in Principle, Resisted in Practice
Challenges of Prevention
Fineberg’s 12 Challenges of Prevention
1) Success is invisible
2) Lack of drama = less interesting
3) Statistical lives = little emo effect
4) Delayed gratification
5) Benefits do not accrue to payer
6) Persistent behavior change required
7) Bias against errors of commission may deter action
8) Avoidable harm = normal
9) Prevention expected to produce net financial return; tx expected to be worth cost
10) Commercial interests may conflict with disease prevention
11) Advice might conflict with personal, religious, or cultural beliefs
12) Advice inconsistent/changes
Fineberg’s Six Strategies to Overcome Prevention Obstacles
1) Pay for prevention
2) Make prevention cheaper than free
3) Involve employers
4) Reengineer to reduce need for individual action
5) Use policy to make right choices easier
6) Use multiple channels to educate, reframe, and elicit positive change
What are the three major requirements of Wellness Programs?
1) Everyone must have an annual opportunity to qualify; alternatives must be available for those needing them
2) Incentive limited to 30% of employee cost of plan (50% for tobacco)
3) Must be “reasonably designed to promote health or prevent disease”
What is the purpose of the US Preventive Services Task Force?
Evaluate evidence regarding preventive services and assign grades
-no cost-effectiveness review
Who supports the US Preventive Services Task Force?
HHS Agency for Healthcare Research and Quality (AHRQ)
Key Issues for Vaccine Policy (5)
1) Administered to healthy individuals
2) Given to very large percentages of population
3) Children primary recipients of most routinely used vaccines
4) Invisibility of benefits compared to confirmed/alleged risks
5) herd immunity
Role of FDA in US Vaccine Policy
Licensure of new vaccines based on safety and effectiveness profiles, etc.
FDA departments involved in US Vaccine Policy
1) Center for Biologics Evaluation and Research (CBER)
2) Vaccines and Related Biological Products Advisory Committee (VRBPAC)
Role of CDC in US Vaccine Policy
1) Advisory Committee on Immune Practices: recommendations for use of approved vaccines
2) Track vaccination coverage, monitor safety (jointly with FDA), assist in promotion and education, etc.
Role of State and Local Governments in US Vaccine Policy
1) Manage immunization info systems
2) Direct promotion and education efforts
3) Administer federal- and state- funded vaccine purchase program, etc.
4) Implement and enforce school entry requirements (mandates), when deemed appropriate
National Vaccine Program Offics (NVPO) and National Vaccine Advisory Committee (NVAC)
high-level programmatic issues
National Vaccine Injury Compensation Program (NVICP) and Advisory Committee on Childhood Vaccines (ACCV)
Financial compensation for vaccine-related adverse events
National Institutes of Health (NIH)
Intramural research and extramural research funding
American Academy of Pediatrics Committee on Infectious Diseases (‘Red Book’)
recommendations
Three roles of the CDC ACIP
1) Develop evidence-based schedule for routine vaccination for children and adults
2) Approve resolutions to add/delete/amend vaccines covered through Vaccines for Children program. No additional approval required
3) Post-ACA, recommendations serve as minimum coverage requirements (with cost-sharing) for insurance plans
Andrew Wakefield
Thimerosal in MMR Vaccine and Autism scam
Vaccines for Children (VFC) Program
Federal program providing vaccines at no cost to Medicaid-eligible, uninsured, underinsured children
-created by Congress in 1993, started in 1994
How is the VFC program funded?
Entitlement program: budget grows as needed without additional appropriations $4.4 billion in 2017
Who is responsible for negotiating vaccine prices for VFC?
CDC and vaccine manufacturers must agree to a contract, but negotiating leverage is minimal. Prices discounted but higher than international prices for the same vaccines
Pneumococcal Vaccine (1998-2000)
budget costs of Prevnar (vaccine) really high; cost effective if the vaccine was cheaper
HPV Vaccination for Males, 2009-11
Not most effective use of public health resources if used on males
Meissner, JAMA, March 2016
Withholding a safe and effective vaccine because of low benefit and high cost is disturbing (e.g. MenB vaccine = lack of routine use will result in a small number but potentially avoidable hospitalizations and death). Value cannot be placed on human life, but resources are finite, and an ethical imperative mandates selection of those interventions that provide the greatest good to the greatest number of people
Men B vaccines in UK
Added to country’s national immunization schedule at lower price
Pauly et al., 2014
Proposal/Framework for incorporating cost effectiveness in ACIP recommendations:
$400k = discouraging
Types of Vaccine Requirements in the US (5)
1) School-entry (States/city)
2) Military personnel (Federal)
3) Select Populations in public health emergencies (states)
4) Immigrants (federal)
5) Health care personnel (employers/states)
School-Entry Requirements/ “Mandates”
Vaccinations required by states and/or cities in order to attend private schools or licensed day-care
- Unvaccinated = not permitted to attend school
What are the types of exemptions for school-entry vaccination requirements?
1) Medical
2) Religious
3) Personal-belief
Supporters of school-entry requirements argue:
1) Would help vaccine to reach recommended groups more quickly, maximizing its potential benefits to individuals and communities
2) Would help to address disparities with respect to vaccination rates and diseases they prevent
Opponents of school-entry requirements argue:
1) Gov’t requiring a vaccine: unnecessary or inappropriate infringement on parental decision-making authority
2) Additional vaccine related adverse events (not acknowledged by policy-makers/scientists) mean that vaccines are unsafe
- or disease so rate that vaccination is unnecessary
- or too early for requirement
Exemptions as free riders
1) Enjoy benefits associated with high vaccination rates (e.g. through herd immunity)
2) Dont assume any of the costs/risks of vaccinations themselves
3) Self defeating if too many choose this
Risk of exemptions to the vaccinated (and those unable to be vaccinated)
1) outbreaks among exemptions
2) Transmission to non-exemptors
Big 3 vaccine manufacturers
GSK, Merck, Sanofi Pasteur
Vaccination Issues in Low and Middle-Income Countries
1) 1.5 million annual deaths worldwide in children under 5 y/o preventable by vaccines current available
2) “Final push” toward global polio eradication (and legacy of smallpox eradication)
3) Devo of ebola and malaria vaccines; others at earlier stages
4) Growth of devo and manufacturing capabilities beyond big 3 multinational vaccine manufacturers
1974 Employee Retirement Security Act (ERISA)
protect employees against abuses on the part of those investing their pension funds and other benefits
-conferred important advantages on employers who covered their own employees’ health care costs (i.e. insured themselves), since they were thereby exempted from state regulation of their health care coverage
HMO
involved in both financing of care and provision of services
Interstudy
research organization that tracked HMOs for federal gov’t
HMO: Staff model
- physicians serve HMO enrollees exclusively
- physician are plan employees
HMO: Group model
- physicians serve HMO enrollees exclusively
- physicians separately incorporated multi-specialty group practice that contracted with HMO
HMO: Independent Practice Association (IPAs)
- Physician services provided through contracts
- HMO physicians allowed to see patients outside of HMO membership
HMO: Network model
HMO contracts with two or more independent group practices
HMO: Mixed
multiple types of arrangements
PPOs
FFS indemnity insurance
- individuals have free choice of providers
Point of Service (HMO)
enrollees allowed to receive partial coverage for services provided outside HMO’s network
utilization management
family of cost containment methods
utilization review
based on retrospective review of records to assess whether services that had been provided to patients were necessary and appropriate
utilization management
carried out by parties accountable to purchasers, review process occurred prior to the provision of services so coverage could be denied for services deemed unnecessary or inappropriate
non-profit conversion to for-profit
when entrepreneurs acquired nonprofit assets for a fraction of their true value (quasi-leveraged buyout) and resold them
e.g. Blue Cross of California lawsuit money –> California Endowment
Robert Alford
dynamics without change to describe heath care in the US - structures have changed but the things that truly matter haven’t done jack shit
Horizontal Integration
Operation of a single organization’s health plans in multiple locations
Advantages of horizontal integration (8)
1) Ability to exploit intellectual capital by replicating successful models and methods
2) Greater access to capital
3) Cost advantages in purchasing
4) Scale economies in expertise and in transaction processing
5) Protection against adverse local conditions provided by geographic diversity
6) Marketing of advantage of a single brand
7) Ability to market and serve national accounts
8) Uniform practices
E. Emanuel, 2008
Three reasons why employer based health insurance sucks:
1) inefficient: take more health insurance than wages
2) tax deduction not free: costs US $210 billion per year
3) inequitable
What Blue Cross influenced
1) Hospitals central provision of medical care
2) Cost increases due to technology are okay
3) American way is not universal health care
4) Middle class works hard
5) Marketing schemes
6) Political influence
Blue Cross vs. Blue Shield
Blue Cross = first hospital plan w/ Baylor
Blue Shield = physician-based insurance plan that wanted to detract from national health insurance efforts
asymmetric information
when one party to a transaction has more info than another party
adverse selection
when unhealthy people over-select (beyond a random distribution) a particular health plan
community rating
geography and family composition to set rates
How is care delivered in TRICARE and to whom?
TRICARE is primarily for active duty service members. It operates out of military facilities and contracts with outside provider networks.
