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 Professor Evans UNIT 6

Introduction to US Health Care Chapter 12 Managed Care

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

Managed Care Features Utilization Reviews – Patients required to get approval from the organization before receiving certain services Provider Networks –Patients must use specific providers who have contracts with the organization Preventative Care – Comprehensive preventative care – cost effective Reduction of Paperwork –Members do not fill out claim forms –Increased paperwork for providers Copayments –Flat fee at time of service Gatekeeper –Members must have referral from PCP to see specialist

Managed Care Organizations Health Maintenance Organizations (HMOs) –Links together a health plan, hospitals, and physicians into a network –Most restrictive type of health plan Give members least choice of selecting health care provider

Managed Care Organizations Preferred Provider Organizations (PPOs) –Similar to HMOs, but do not have PCP as gatekeepers –Don’t need referral to see specialist –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 (But don’t require) use of gatekeeper –Choose out of network provider (with penalty)

Assessing Performance Impact on quality and cost –Expectation is that having PCP to oversee general care and act as gatekeeper will increase quality and reduce health costs This has not been supported by evidence Impact on physicians and health care providers –Physicians receive less for services than they used to & their expenses have increased due to administrative costs –Physician professional satisfaction is falling

What are some positive characteristics of HMOs? What are some negative characteristics of HMOs?

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 –Increased competition –Changing due to managed care Burgeoning health care systems –Becoming larger and more complex Higher expectations of accountability –New federal legislation –Rules relating to makeup of the board (directors without a financial stake)

Challenges Facing Health Systems Mergers and acquisitions produced Complex and unwieldy organizations Cost reductions have not been realized or achieved Purchase of physician practices and providing services have produced huge losses in various investments Integration of systems has been problematic

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 –People are healthier today than they were years ago Biomedical and pharmacological technologies –Advances in treatment strategies and drug technologies mean better results and shorter recovery times The way health care is provided –As treatment shifts from inpatient to outpatient, the cost for providing services decrease Financing priorities –Insurance plans, managed care plans, and medicare try to control costs by rationing care Short-Term Care

Aging and Demand For Services An increase of chronic disease –As population ages so does chronic health conditions Disappearance of nearby extended family –Fewer extended families stay in one area has an impact on care options for elderly Long-Term Care

The Underserved Populations Increasing diversity in the workforce –Increasing percentage of underrepresented minorities in medical profession Changing education –Select, train, and deploy more health care works who choose to practice in rural areas Changing reimbursement strategies –Providing incentives Changing federal and state programs –Creating programs that provide direct services to underserved areas Relying on the impact of managed care –Managed care effect in rural areas are just beginning to be felt

UPCOMING WEEK-UNIT 7 Attend seminar –Or complete Option 2 and post in dropbox by Tuesday (10/11) at 11:59EST Discussion –Initial by Saturday (10/08) at 11:59EST –Two posts to classmates discussion by Tuesday (10/11) at 11:59EST Unit 7 quiz –Due Tuesday by 11:59 EST (10/11) –10 T/F or Multiple Choice, 5 Short Answers, 1 Essay

FINAL EXAM TWO HOURS COMPREHENSIVE –Covers all chapters we covered this term 42 Questions –36 T/F or Multiple Choice –10 Short Answers –2 Essay questions

Introduction to US Health Care Chapter

Public Health Services Protection of the nation’s public health is a government responsibility. Assessment –Must understand community health needs, recognize health hazards, and understand their causes and impacts Policy Development –Advocate and build constituencies –Set priorities, goals, and outcomes Assurance –Making sure public health policy is implemented 14-22

QUESTION If you were charged with addressing proximity to medical care, what health policies would you introduce?

The Department of Health & Human Services (DHHS) The DHHS and various federal agencies perform several public health functions. CDC: Data gathering and analysis, and surveillance and control NIH: Conducting and sponsoring research FDA: Ensuring the safety of food and drugs CMS: Ensuring access to health services by aged and poor people Providing direct services to special populations: Indian Health Service is agency that performs this function 14-24

State Health Agencies The state’s role in public health: Licensing health care professionals Inspecting and licensing health care facilities Collecting vital statistics 14-25

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 14-26

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 14-27

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 14-29

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 14-30