US Healthcare System verified (2022/2023)

US Healthcare System verified (2022/2023)7 Descriptions of US Healthcare 1. We cost more 2. We die sooner 3. Our medical care is less effective 4. Our system is inequitable and resistant to learning 5. We are less happy with it 6. Health care is eating our paychecks 7. You will be paying for me Elements of US Health Care "system" patients providers payers government 00:48 01:08 Sources of insurance coverage in 2012, % Employer-48.4% Medicaid/CHIP-13.8% Medicare-15.7% Uninsured-15.4% Sources of health care spending, % Private-33% Medicaid-15% Medicare-20% Vince Mor Axiom Its all your money: many channels, one source Individuals have what 3 sources of health care coverage? employer government direct purchaser What are the different types of government health care coverage? Medicare Medicaid VA Indian Health CHAMPUS What are the different types of employer health insurance? Fully-insured Self-insured What are the 3 challenges to using insurance model for medical care? 1. "Two in one" goal of health insurance: routine maintenance and catastrophic expenses 2. Service pricing: In auto and fire: the "event" and cost are determined by contract 3. 3rd party health care financing: The user is not the buyer (moral hazard) What are the three legs of the ACA "stool"? 1. Individual Mandate 2. Low income-Medicaid 3. Moderate income-Exchanges How much do we spend on Medicare and how many people? About 20% of US Healthcare dollar and covers about 50 million (15.7%) What are Medicare's major historical events? 1965-signed into law by Pres. Johnson, 65's 1972-Expanded to include disabled 2003-drug coverage 2010-ACA 00:02 01:08 What are the four sets of Medicare benefits? 1. Part A-Hospital (Inpatient) 2. Part B-Supplementary Medical (Outpatient) 3. Part D-Drug 4. Part C (Medicare Advantage)- A, B, and D combined by a private insurer What are 5 criticisms of Medicare? 1. Very limited LTC, no dental, hearing aids or glasses 2. Not really insurance-no limit on out of pocket spending 3. Pays about half of beneficiaries total health and LTC spending 4. Payments go up with age 5. Sick people pay more What proportion of beneficiaries make up the majority of Medicare costs? 10% account for 60% of $$$ What are the 3 ways that Medicare is affected by the ACA? 1. Closes the donut hole by 2020 2. Solvency Improvements 3. Long term payment reform How much do we spend on Medicaid and how many people? About 16% of US Health Care dollar, covers about 50 million after ACA When was Medicaid enacted? 1965 by President Johnson What are 5 roles that Medicaid plays in our health care system? 1. Health insurance coverage 2. Assistance to Medicare beneficiaries 3. LTC assistance 4. Support for Healthcare system & safety-net 5. State capacity for health coverage What is FMAP and how is it calculated? Federal Medical Assistance Percentages and its baseline is set at 50% and is higher for certain states based on per capita income What were the original categories of people that qualified for Medicaid? blind, disabled, and families living in poverty receiving cash assistance Pre-ACA what was Medicaid broadened to cover? higher income children (CHIP), pregnant women, low-income parents, special needs children, low-income disabled adults, low income elderly (Duals) In what populations does Medicaid play a big role? Non-elderly/children below 100% FPL, HIV, Nursing home What are the major populations left out of Medicaid Pre-ACA? Childless adults (large majority of uninsured) low-income parents 5 year wait for legal adult immigrants Eligible does not mean enrolled What does Medicaid pay for? physician, NP, midwife, lab, imaging, nursing home, transportation What are 3 major differences between Medicaid and private coverage? 1. Limited or no cost sharing 2. Covers long-term care 3. Specifically covers high risk, high cost populations (elderly, disabled) What proportion of beneficiaries make up the majority of Medicaid costs? 25% drive 65% of $$$ How many "duals" are there and what proportion of Medicare and Medicaid are they? 9 million, 20% of Medicare, 15%of Medicaid, drive more Medicaid than Medicare spending About how much of state budgets does Medicaid consume? About 16% What are 4 Medicaid cost control strategies? 1. Provider reimbursement rates 2. Elimination of (or limits on) optional services 3. Roll back eligibility for optional populations 4. Purchasing for greater value How was Medicaid impacted by the ACA? Option to expand Medicaid to 138% FPL Category of eligibility removed Increased FMAP Health Homes option Reduced DSH allotments How much do we spend on private insurance and how many people? About 33% of US Health Care dollar and 55% of the US population What is the definition of health insurance? it is a contract in exchange for a fixed amount (premium), insurer will pay a certain amount for certain medical services received by people named in the contract What are covered services? list of services to be paid for What is benefit design? Terms and conditions of coverage What is benefit administration? How the terms and conditions of coverage are administered What is a premium? amount paid on a regular basis (monthly) to be a member of a plan (pre-tax) What is a deductible? Member's out-of-pocket cost before any payment by insurance company What are coinsurance(%) and co-payment(fixed)? amount owed by member when they get a service, even after paying the deductible What are the six major time periods in the history of private health insurance? 1. 1940s-Employer insurance, artifact of WWII 2. 1960s & before-health insurance paid in full by employers and covered inpatient care 3. Advent of Medicare & growth of outpatient services (cost-sharing) 4. 1980s-managed care(limited cost-sharing) 5. Late 90's-demise of managed care and increased cost sharing 6. 2010s-shift of responsibility for determining what is needed to providers What are six features of Managed Care? 1. narrow networks 2. lower provider prices 3. gatekeeper models 4. pre-screening 5. prevention is a priority 6. removes waste What is the goal of an actuary? estimate the probability of cost incurred for a defined group as accurately as possible (good underwriting) What are some potential risk factors to allocate health insurance costs? age, gender, geo region, industry, smoking, BMI, genetic, family size, etc. What is adverse selection? when risk pool get polluted (too many sick and not enough healthy) What are 3 ways insurers deal with adverse selection? 1. avoid the risk 2. price them accordingly 3. attract the low risk What are 3 consumer effects of adverse selection? 1. "job lock" 2. Uninsurables 3. Affordability What are 5 federal standards for health insurance in the small/individual markets? 1. Individual mandate 2. Essential Health Benefit (10) 3. Fixed rating factors (age, geo, family size) 4. Rate band limits (3:1) 5. No medical underwriting What are the 5 Iron Laws of Health Insurance? 1. Rating: we can predict but can't decide what to do with this information 2. Voluntary health insurance is hard to do 3. Employer purchase adds pricing complexity (moral hazard) 4. Its the costs stupid-most pricing is about shifting costs, not reducing them 5. Change is hard (ACA makes it fairer/consistent but at the price of oversight) What are 4 measures of quality? 1. Structure 2. Process 3. Outcomes 4. Patient Experience What are 3 types of quality errors? 1. overuse 2. underuse 3. misuse What is the IHI Triple Aim? 1. Improve the patient experience of care (quality and satisfaction) 2. Improve the health of a population 3. Reduce per capita cost of health care What is an equation for value? (Appropriateness+quality)/Cost to Patient What are two factors that explain costs in the health care? 1. Excess costs 2. Excess rates of increase (trend) What are average costs in health care? Expenses per capita = # of services*price per service What are total costs in health care? expenses per capita*population What is the main driver of costs in health care? Price What are the 4 volume factors that most contribute to growing costs? 1. Service volume drives revenue 2. Lifestyle and behavior 3. Lack of provider coordination 4. Lack of evidence based care What are the 3 price factors that most contribute to growing costs? 1. Provider consolidation 2. Lack of price-based competition 3. Consumers preference for brand name providers and services