US Health Care Payment System Flashcards
Who pays for health care services
3 ways its paid
1) private insurance
2) government insurance
- Medicare (elderly)
- Medicaid (poor)
Self pay
- co-pays
- deductibles
Examples of payers in government health care
Medicare, Medicaid
Examples of providers in government healthcare
VA, state and county hospitals
Examples of regulators in governmental healthcare
CMS, state licensing, medical boards
Central issues with US healthcare
Access
- 15% population is not insurance
Cost
- costs on average 10k a year per person
Quality of insurance for the cost
- 37th in the world and only modest life expectancy yet top 3 most expensive
The “triple aim”
Ideal insurance model which focuses on 3 areas to a good health care system with improved experience in care
Experience of care
Health of the population
Per capita cost
Difference between US and European health care models
US focuses vast majority (97%) to treating diseases with a small minority (3%) going towards preventing diseases
European is closer to 70/30 respectively
Fee-for-service system
Based on sickness and volume levels
More reactive than proactive and more focused on making money.
Not very effect system but is current system in the US
Is prone to Medicare fraud
Financially safe and administratively simple
Payment is retrospective
More you do = more money
Results from the fee-for-service system
40-50% of medical care is wasteful
75% is used to treat preventable diseases
13.5% of Medicare patients experience adverse events
Transaction costs are stupid high
Patient Protection and affordable care act (PPACA) (2010)
Most significant overhaul of insurance since 1965
Helped cut uninsured numbers in half and focus more on preventative care and vaccinations
Medicare Access and CHIP Reauthorization Act (MACRA) (2015)
Significant changes in Medicare allowed for reimbursement for physicians
Established a new framework for rewarding quality and value vs volume
Narrow networks
Created by governmental payers that steer patients towards select hospitals and physicians
Designed to help patients find high quality/low cost provider panels (don’t actually do this though)
Examples of quality metrics in health care
PQRS
Hospital ranks
HEDIS
- most commonly used
National quality forum
AHRQ
CAHIPS
What is the most common reimbursement model in play today
Fee-for-service
Pay for performance reimbursement model (P4P)
A shift toward value of care = more money rather than volume = more money
