Introduction to US Health Care Text by Dennis D. Pointer, Stephen J. Williams, Stephen L. Isaacs & James R. Knickman with Tracy Barr PowerPoints by Robin Pickering Eastern Washington University

Introduction to US Health Care Chapter 12 Managed Care

Controlling Costs Controlling Access Referrals Type of care Specify provider Controlling Price Negotiate fees with in-network providers

Ensuring Quality Policy Based Upon… Medical Research? Cost Reimbursement? Care Provided… PCP thinks is appropriate? Administrators think is appropriate?

Managed Care Features Utilization Reviews Provider Networks Preventative Care Reduction of Paperwork* Copayments Gatekeeper Patients required to get approval from the organization before receiving certain services

Managed Care Features Utilization Reviews Provider Networks Preventative Care Reduction of Paperwork* Copayments Gatekeeper Patients must use specific providers who have contracts with the organization

Managed Care Features Utilization Review Provider Networks Preventative Care Reduction of Paperwork* Copayments Gatekeeper Comprehensive preventative care – cost effective

Managed Care Features Utilization Reviews Provider Networks Preventive Care Reduction of Paperwork* Copayments Gatekeeper Members do not fill out claim forms Increased paperwork for providers

Managed Care Features Utilization Reviews Provider Networks Preventative Care Reduction of Paperwork* Copayments Gatekeeper Flat fee at time of service

Managed Care Features Utilization Reviews Provider Networks Preventative Care Reduction of Paperwork* Coypayments Gatekeeper Members must have referral from PCP to see specialist

Managed Care Organizations Health Maintenance Organizations (HMOs) Preferred Provider Organizations (PPOs) Point-Of-Service (POS) Plans

Managed Care Organizations Health Maintenance Organizations (HMOs) –Links together a health plan, hospitals, and physicians into a network

Managed Care Organizations Preferred Provider Organizations (PPOs) –Similar to HMOs, but do not PCP as gatekeepers –Tend to require greater out-of-pocket payments from members

Managed Care Organizations Point-Of-Service (POS) Plans –Combination of HMO and POS (choose each time) –Encourage use of gatekeeper –Choose out of network provider (with penalty)

Assessing Performance Impact on quality and cost Impact on physicians and health care providers

Introduction to US Health Care Chapter 13 Promoting Health and Preventing Disease

U.S. Health Care System Growing in complexity –Advances in medical science and technology –Evolving understanding of the human body –Increase in demand for treatment

The Effect on Governing Boards Economic dynamics Burgeoning health care systems Higher expectations of accountability

Challenges Facing Health Systems Complex and unwieldy organizations Cost reductions have not been realized Huge losses in various investments Integration of systems has been problematic

Financing Health Care Health Care Costs Number of Insured Growing number of uninsured Enter system sicker = boost in cost General inflation Increased medical expense Increasing population Increase in demand

Incremental Change… Limiting federal government health care expenditures Making health insurance plans more accountable and patient-friendly

Funding Medicare Largest health plan and payer of hospital and physician services Rising costs and increasing population create major problem Bankrupt? Reconfigure Medicare? What Goes In = What Comes Out???

Potential Reconfigurations Increase age limits Increase taxes and contributions Limit coverage Restrict benefits Increase coinsurance and deductibles Reduce payments

Aging and Demand For Services Changes in lifestyle Biomedical and pharmacological technologies The way health care is provided Financing priorities Short-Term Care

Aging and Demand For Services An increase of chronic disease Disappearance of nearby extended family Long-Term Care

Challenges for Primary Care The “cult” of specialization Too few generalists, too many specialists The impact of managed care Lack of government direction Changing medical models

The Underserved Populations Increasing diversity in the workforce Changing education Changing reimbursement strategies Changing federal and state programs Relying on the impact of managed care Fixing the Problem…

Other Challenges… Advancing technology Shortage of nurses Evolving public health threats Declining financial health of hospitals

Introduction to US Health Care Chapter 14 Public Health Policy 14-29

Public Health Services Protection of the nation’s public health is a government responsibility. Public Health Agencies Three core functions are Assessment Policy Developme nt Assurance 14-30

The Department of Health & Human Services (DHHS) The DHHS and various federal agencies perform several public health functions. Data gathering and analysis, and surveillance and control: The CDC Conducting and sponsoring research: The NIH Providing programmatic assistance to state and local governments 14-31

The Department of Health & Human Services (DHHS) The DHHS and various federal agencies perform several public health functions. Ensuring the safety of food and drugs: The FDA Ensuring access to health services by aged and poor people: The CMS Providing direct services to special populations 14-32

State Health Agencies The state’s role in public health: Licensing health care professionals Inspecting and licensing health care facilities Collecting vital statistics 14-33

The state’s role in public health ( contd.) Investigating and analyzing the epidemiology of disease Epidemiology study includes three factors: 1.Incidence 2.Distribution 3.Control 14-34

The state’s role in public health (contd.) Observing and managing communicable diseases in the community Registering diseases and tumor information Providing laboratory services Formulating health policy and legislation Analyzing health policy and legislation’s impact Providing community health education 14-35

Food safety inspection Sanitation services Investigation and control of STDs Drinking water purification Local Health Agencies Most front-line public health services are provided locally

Private Health Care Providers Private health care providers contribute to the public health by: Engaging in surveillance and monitoring of diseases Administering immunizations Screening for communicable diseases Offering patient education Coordinating the provision of private and public health services 14-37

Researchers conduct surveys comparing the U.S. population to populations in other developed countries. Key indicators are:  Cost  Access  Responsiveness  Infant mortality  Fairness of financing Health Indicators 14-38

To classify health systems researchers look at a number of factors.  Degree of primary care regulation  Type of financial access to health care  Whether the health system relies on generalists or specialists to provide primary care Characteristics of the Health System 14-39

To determine if a the foundation of a country’s health system is primary or specialty care researchers look at the following factors:  Extent to which the PCP acts as the point of entry into the system  Extent to which the physician provides continuous care over time  Comprehensiveness of the care provided  Extent of coordination of services by the PCP Primary Care or Specialty Care 14-40