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_______ = allocation of resources & issues in the production & distribution of health care

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Health care economics

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_________ = refers to the total dollar value of all goods and services produced by an economy in a specified time; quarterly or annually. - ~ 18% of our GNP goes to health care, ~9% 1980

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Gross National Product {GNP}

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Financing Health Care: Where it comes from and where it goes. - Comes from: ________ - Goes to: _______

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1. Private health insurance, Medicare, Medicaid, Out-of-pocket, other government programs 2. Hospital care, other personal health care, physician services, other spending, nursing home care

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Where does our $$ go?? 1. 2. 3. 4. 5.

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1. Health Services and supplies 2. Administration costs 3. Government public health activity 4. Un-insured 5. Under-insured

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_____________: - out-of-pocket "cost sharing" - Employer share - Employee share - Medicare - Medicaid - Public costs - Federal tax subsidies - Private costs - State tax subsidies

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Public & Private Sources of Payment

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Health Care Spending - Health care costs in the U.S. are massive - Expenditures (GDP) have more than ______ in the last four decades: 2010 - 17.9% 2008 - 16.2% 2003 - 15.6% 1998 - 13.5% 1990 - 12.3% 1980 - 9.1% 1970 - 7.2%

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1. doubled

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Health Care Spending - Health care spending is _____ times the amount spent on national defense - It is projected that health care will reach _____ of the GDP by 2019 (CMS, 2010) - Americans average about $_____ per year on drugs - prescription drug costs increase 5-6% per year

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1. 4.3 2. 20% 3. $2,300

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In 2010 ____ paid for 46.2% of health care costs.

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1. Government

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Health Care Financing Reasons for the high costs include: 1. 2. 3. 4. 5. 6.

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1. Growth in private insurance and third party reimbursement 2. Rapid increase in the income of health care providers 3. Changes in population demography 4. Lifestyle choices (smoking, diet, obesity) 5. Increase in the numbers of uninsured individuals 6. Dependence on technology

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Health Care Financing Composed of a combination of: 1. 2. 3.

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1. Fee-for-service 2. Public sector payment 3. Third party reimbursement

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Health Care Financing Composed of a combination of: Fee-for-service - _______

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1. Out of pocket - cost sharing

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Health Care Financing Composed of a combination of: Public Sector - ________ - ________ - ________

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1. Medicare 2. Medicaid 3. Public cost

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Health Care Financing Composed of a combination of: Third party reimbursement - ________ - ________

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1. Employer share of premiums 2. Employee share of premiums

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____________: - Enacted in 1965 as an amendment to the Social Security Act - Federal health insurance program ------ People 65+ ------ Some persons with disabilities ------ Those with end-stage renal disease - Administered by the CMS (Center for Medicare and Medicaid Services) - Financed through tax wages - Largest insurer in the U.S.

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Medicare

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Medicare ________: - Hospital and skilled nursing facility care - Home health - Hospice care - Blood - Most U.S. residents are eligible for this premium free - provided they or their spouse has contributed to the program more than 7.5 years.

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Medicare Part A

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Medicare __________: - Physician services - Outpatient services - Home health care - Durable medical equipment - Some other services (ambulance, some supplies) - requires a monthly premium ($100.00-220.00) (2012 - based on income), deductibles ($162/year) and co-pay (20%)

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Medicare Part B

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Medicare __________: - Capitated benefits package offered by private insurance companies - may require a monthly premium in addition to Part B, but many don't - Have become very population in last 5-6 years - About 25% of elders are enrolled in this - Expensive for federal government and subsidies are reduced/eliminated in ACA

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Medicare Part C - Medicare Advantage

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Medicare _________: - Prescription drug coverage Medicare Part D is based on the Medicare Modernization Act of 2003 - Provides all beneficiaries with the option to add prescription drug coverage - Requires a plan premium ($35-37/month) + Medicare monthly premium $12-70 (based on income) and a deductible of $250/year - People who currently had Medicare enrolled between Nov 15, 2005 and May 15, 2006 - Each enrollee elects coverage and choose a Prescription Drug Plan or Medicare Advantage Plan

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Medicare Part D

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Medicare Part "D" - Beneficiaries pay ___% of drug costs between $250 and $2,250 (up to a maximum of $500) - For amounts between $2,251-5,100, the individual pays ____% (up to a maximum of $2,850) - After total drug costs over $5,100 or out of pocket of $3,600, the beneficiary pays ____%

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1. 25% 2. 100% 3. 5%

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Medicare does not cover: 1. 2. 3. 4.

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1. Dental care 2. Custodial care 3. Health care outside of the U.S. 4. Hearing aids

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_______ and _______ make up the majority of medicare expenditures.

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1. Hospital Care (31%) 2. Physician/Clinician Services (21%)

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Medicare - Before 1983 Medicare paid providers on a ______ basis.

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1. Fee-for-service 2.

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Medicare - Before 1983 Medicare paid hospitals on a ______ basis

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1. cost-based retrospective

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Medicare - ________ created the prospective payment system (PPS)

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1. The Social Security Amendment of 1983

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Medicare - The Prospective payment system (PPS) uses _______ to classify cases for reimbursement.

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1. Diagnosis-related groups (DRGs)

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Medicare is based on a _____ per case

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1. Fixed price

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__________: - Began in 1965 by Title XIX of the Social Security Act - Is public assistance welfare program - Provides assistance to pay for health care for the poor, blind, disabled and families with dependent children - Funded jointly by the federal government and each state - Eligibility, coverage and payment vary greatly from state to state. - Recipient must meet financial and eligibility requirements

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Medicaid

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Medicaid Covered Services: 1. 2. 3. 4. 5. 6. 7.

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1. Inpatient and outpatient hospital care 2. Skilled nursing care 3. Physician services 4. Family planning services 5. Home health care 6. EPSDT services 7. Laboratory and X-ray services

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Medicaid - Services that may be covered include: 1. 2. 3. 4. - There are no costs to those eligible for Medicaid - Payment is based on _____ with some exceptions

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1. Dental care 2. Eye care 3. Medications 4. Psychiatric care 5. Diagnosis-related groups (DRGs)

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Medicaid - Coverage is more prevalent among _______. - 22% under age 6 - 32% ages 6-20 - 31% ages 21-64 - 11.5% over age 65

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1. Younger aged children

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Medicaid Coverage - More than half is care for ______ (20% of all children in the U.S. are eligible for Medicaid) - 21% adults (mostly _______). - 18% _____ - 11% _____

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1. Children 2. Pregnant women 3. Blind and disabled 4. those 65+

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Most of Medicaid expenditures go to _______.

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1. Nursing Home Care

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Most of the people enrolled in Medicaid are _______, but most of the expenditures are by _______.

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1. Children 2. Disabled

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Medicaid Spending - States spend about ____% of funds on Medicaid - In comparison, states spend ____% on elementary and secondary education and ____% on higher education.

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1. 14.6% 2. 35% 3. 13%

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____________: - 15.4% of all children were not covered by health insurance in 1998 - Part of the Balanced Budget Act of 1997 - Covers low-income children not eligible for Medicaid - Similar to Medicaid (funded jointly by states and federal government) - Most states participate

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State Children's Health Insurance Program (SCHIP)

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Private Health Care Financing - Historical Perspective - Until the 1930s ______ was the most common method of health care financing. - Most health care providers donated services to charity - ___________ ------- Teachers paid a sum of money each month to cover hospital care (Blue Cross) ------- Later premiums were added to cover ------- costs of physician care (Blue Shield)

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1. private payment 2. In 1929 Dallas school teachers negotiated a pre-paid health provision contract with Baylor Hospital

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Health Care Financing - Historical Perspective - Concept of ________ became popular - Employers used ______ to supplement worker's benefits - Health care providers recognized guaranteed payment or services

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1. Paying a small fee for health care 2. Health insurance

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____________: - Major source of financing for health care - Frequently provided by employers and is an expected benefit of employment ------ about 65% of non-elders are insured by employers - Health care insurance programs include various financial arrangements Traditional indemnity coverage ------ PPOs ------ HMOs

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Private Health Insurance

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Private Health Insurance - Insurers pay for portion of care for enrollees - ______, ______, and _______ are cost-sharing methods. - To curb costs, health insurers developed 'managed care' options - Covered services typically include: 1. 2. 3. 4.

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1. Co-payments 2. Deductibles 3. Coinsurance 4. Hospitalization costs 5. Physicians care 6. Medications 7. Dental costs are provided by many plans

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Private Health Insurance Overall insurance coverage eroding due to: 1. 2. 3. 4. 5.

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1. Rising premium costs 2. Trend toward temporary and part-time work 3. Reduction in pharmaceutical benefits 4. Grater limitations on covered care 5. Rising cost of "Medigap" coverage for elders

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Private Health Insurance - Health expenditures increased by 9% in 2011 over 2010 - The primary reason people are uninsured is ______ - About 50% of the American public says they are very worried that they will need to pay more for health care and insurance

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1. insurance coverage is too expensive

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Private Health Insurance _________: - Enacted in 1985 - Protects unemployed and their dependents who have lost their benefits - Self-financing or out-of-pocket payments - Benefits continued for a defined period

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Consolidated Omnibus Budget Reconciliation Act (COBRA)

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Access and equity - Underinsured - 25 million Americans are underinsured - In 2007, ____% of Americans surveyed had problems paying medical bills, faced bill collectors, or were in debt for medical care ------- Up from 34% in 2005. ------- The majority reported having insurance at the time these bills were incurred

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1. 41%

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Access and equity - Uninsured 45 million Americans have no health insurance - 7% of _______ - Most are _____, ______, ______, and _____. - 66% are in families of employed workers - Nearly half of the uninsured are _____ or _____. - States with well-funded Medicaid have lower rates ------- Minnesota, Hawaii, Iowa, Wisconsin & Maine - lowest ------- Texas - 24% uninsured; worst in country

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1. Non-elderly population 2. unemployed, 3. minority, 4. younger (under 35) 5. low-income/moderate income 6. self-employed 7. employed in small companies

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_____ (race) makes up the highest percentage of uninsured.

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Latino

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The likelihood of being insured increases as level of ______ rises.

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Educational attainment

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___________: - use fewer preventive and screening services; - are sicker when diagnosed; - receive fewer therapeutic services; - have poorer health outcomes (higher mortality and disability rates); and - have lower annual earnings because of poorer health.

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The Consequences of Being Uninsured 1. Research demonstrates that the uninsured:

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Other "Insurance" ___________: - State administered program - Requires employers to pay health care costs of workers who sustain illness or work-related injuries associated with their job - may also pay percentage of salary/wages while individual cannot work

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Workers' Compensation

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Trends in Health Financing - __________ - efforts by employers to shift part of the burden of health care costs to the employees ------ Premiums ------ Deductibles ------ Co-payment or coinsurance - Significant increase in use of cost sharing strategies over the last two years

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1. Cost Sharing

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Trends in Health Financing - _________ - Alliances or collaborative arrangements between a group of hospitals, physicians and ancillary providers -------- Creates a system that provides comprehensive health services -------- Designed to improve services within a geographic market -------- Help control costs by improving purchasing power (discounted buying) and group contracting

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Integrated Delivery Systems

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Trends in Health Financing - Health Deductible Health Plans - ________ - health programs in which employers fund benefit plans from their own resources -------- Self-funded plans often use an outside source as administrator -------- Self-funded plans often limit liability via stop-loss insurance

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1. Self-insurance

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Trends in Health Financing _________ - a benefit offered by employers that help employees pay for health expenses with pre-tax dollars - Pay for uncovered portions of qualified medical costs. ------ Co-payments; deductibles ------ Orthodontia and dental care ------ Prescription drugs; some non-prescription drugs ------ Contact lenses ------ Hearing aids/batteries ------ Laser eye surgery ------ Fertility treatment - Employees determine how much they wish to pay into their FSA (generally up to $4,000 for an individual and $5,000 for dependent Care)

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Flexible Spending accounts (FSA)

question

Health Insurance Reform __________: - Several efforts - dating back to the early 20th century (not passed with Medicare/Medicaid) - The early 1990s with Clinton's health plan (Managed Competition) _______ was signed into law March 2010.

answer

1. National Health Insurance 2. Patient Protection and Affordable Care Act was signed into law March 2010

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____________: - Individual Mandate - Requires U.S. citizens and legal residents to have health coverage - Employer Requirements - Requires employers with more than ____ employees to offer coverage or vouchers - Expansion of Medicaid - Expands Medicaid to all individuals under age 65 with incomes up to ___% of the federal poverty line - Expansion of CHIP - Requires states to maintain current income eligibility levels for children enrolled in CHIP until 2019 - Premium and Cost-Sharing Subsidities - Creates insurance exchanges to provide premium credits and subsidities to qualifying individuals and families - Changes to Private Insurance - Cost Containment Provisions - Prevention and Wellness

answer

1. Patient Protection and Affordable Care Act - 2010 - Selected Provisions 2. 50 3. 65 4. 133%

question

Patient Protection and Affordable Care Act - 2010 - Selected Provisions __________: - Establishes a temporary national high-risk pool to provide health coverage to individuals with pre-existing medication conditions - Establishes a process for reviewing increases in health plan premiums and requires justification of increases - Provides dependent coverage for children up to age 26 for all individual and group policies - Prohibits health plans from placing lifetime limits on the dollar value of coverage and from rescinding coverage - Permits states to form health care choice compacts and allow insurers to sell policies in any state participating in the compact.

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Changes to Private Insurance

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Patient Protection and Affordable Care Act - 2010 - Selected Provisions __________: - Requires rules to simplify health insurance administration - Restructures payments to Medicare Advantage plans - Acts to reduce waste, fraud and abuse in public programs

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Cost Containment Provisions

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Patient Protection and Affordable Care Act - 2010 - Selected Provisions ___________: - Covers preventive services and eliminates cost-sharing for preventive services in Medicare and Medicaid - Requires qualified health plans to provide preventive services, recommended immunizations, preventive care for infants, children and adolescents and additional preventive care and screening for women - Provides grants for small employers who establish wellness programs - Requires chain restaurants and foods sold from vending machines to disclose the nutritional content of each item

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Prevention and Wellness

question

Patient Protection and Affordable Care Act - 2010 - Selected Provisions Note: A few of the provisions were enacted in 2010, but most will not take effect until 2014 and the Act will not be fully implemented until 2018 Legal challenges have commenced and are projected to stall implementation of some provisions

answer

Notes

question

___________: 1.Promote/require transparency in pricing for health services 2. Deregulate insurance a. Allow/promote/encourage low premium, high deductible policies b. Enhance/promote health savings accounts 3. Amend /consolidate/ standardize State Practice Acts to allow NPs and PAs to provide care for which they are educated 4. Legalize/legitimize international purchase of pharmaceuticals 5. Death penalty for Medicare fraud and abuse (not really, but there must be REAL attempts to stop this)

answer

Healthcare Reform Ideas that might really make a difference

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