1. Western Health Insurance and Eastern Healthcare
Presented by: Michelle Loose, CPhT
Envision Student Forums – Nursing and Healthcare, 2014

2. Topics Health Insurance – HMO vs PPO Medicare/Medicaid
Typical Hospital Billing
Bundled Payments for Care Improvement (BPCI) Initiative
Traditional Chinese Medicine (TCM) and Western Medicine

3. Health Insurance Terms to Know
Deductible – amount a patient pays toward his/her medical bills before insurance starts to pay
Premium – cost of keeping insurance policy in effect
Copayment – fixed dollar amount a patient pays each time s/he receives medical services

4. Health Management Organization (HMO)
Insurance plan usually associated with cost
Lower cost to patient – low co-payments, no deductible
Limited choices of physicians and restrictions on when patient can receive care
-Must choose from a list of pre-approved providers/physicians
-Must get approval from primary care physician to see a specialist

5. Preferred Provider Organizations (PPO)
Insurance Plan usually associated with access
More healthcare options – able to see any doctor without prior approval while in-network and out-of- network
Higher deductible costs and more paperwork to claim reimbursement

6. HMO vs PPO HMO PPO Prefer fewer billing hassles
Need to keep out-of- pocket costs lower
Have a family that will only need annual physicals, baby visits and OB/GYN care
Want to be able to choose any doctor
Have a chronic condition, such as back pain or arthritis
Would like to use alternative medicine such as Traditional Chinese Medicine

7. Medicare/Medicaid
Medicare – essentially public healthcare insurance for the elderly
Medicaid – essentially public healthcare insurance for people with low income
Both have multiple insurance options
Medicaid has HMO/PPO options

8. Hospital Billing
Standard of billing varies throughout the United States due to billing preference, billing software and type of insurance
Hospital billing differs between in-patient and out-patient care

9. Hospital Billing In-Patient Out-Patient
Billed per diagnosis – bundled payment for medicare/medicaid
Per medicare/medicaid guidelines, hospitals charge a certain amount no matter how many tests or medications were needed
Includes treatment in hospital observation units
Hospitals can charge per test and medication needed
Not necessarily bundled or per diagnosis

10. Receiving a Hospital Bill
No Insurance – the patient will receive separate bills for radiology (e.g. X-rays), hospital stay and physician charges
Private Insurance – the patient will receive a copy of the bill and costs may vary
Medicare/Medicaid – the patient may also receive a copy of the bill but the cost may not vary
Price of personnel (e.g. nurses) and the room are built into the cost
Hospital Costs are for procedures, not personnel

12. Medicare Bundled Payments for Care Improvement (BPCI) Initiative
4 Models of Care currently being tested
Model 1: Acute Stay – hospital inpatient only
Model 2: Acute Stay Plus Post Acute Care (PAC) – inpatient, physician, all post-acute services, readmissions
Model 3: PAC – Physician, all post-acute services, readmissions
Model 4: Acute Stay – single payment for all hospital and physician services associated with an inpatient stay
Goal: To improve quality of care rather than reward based on quantity of services offered to patients; more coordinated care at a lower cost to Medicare/Medicaid

13. TCM and Western Medicine
Challenges in incorporating TCM into western medicine hospitals and our need to “scientifically prove” TCM’s results via clinical trials
Research into incorporating TCM in Western Medicine treatments
Arsenic Trioxide traditionally used in TCM and approved by the USFDA in 2000 for Acute Promyelocytic Leukemia (APL) cancer treatment

14. TCM and Western Medicine at Northwestern Memorial Hospital (NMH)
Does not specifically use TCM as a treatment option
NMH stopped acupuncture a few years ago
NMH does employ massage therapists

15. Traditional Chinese Medicine (TCM) and Western Medicine
“These substances may have not been thoroughly tested to find out how they interact with medicines, foods, or dietary supplements. Even though some reports of interactions and harmful effects may be published, full studies of interactions and effects are not often available. Because of these limitations, any information … should be considered incomplete.” -American Cancer Society, Chinese Herbal Medicine
"It gives a lot of optimism of seeking other types of cancer medicines in the Chinese pharmacopedia, which many people are looking into.” -Samuel Waxman, MD, Mount Sinai Hospital, regarding Arsenic Trioxide use in cancer patients (qtd. In Yu)

16. Works Cited
Bundled Payments for Care Improvement (BPCI) Initiative: General Information. Innovation.CMS.GOV. 27 May <innovation.cms.gov/initiatives/bundled-payments> Chinese Herbal Medicine. American Cancer Society, 26 April May < ntaryandalternativemedicine/herbsvitaminsandminerals/chinese-herbal-medicine> Fargen, Ashley, PharmD. Personal Interview. 30 May Health Maintenance Organization HMO Law & Legal Definition. USLegal.com. 21 May < Loose, Margaret, RN. Personal Interview. 25 May Mangan, Laura, RN-BSN. Personal Interview. 21 May Yu, Alan. Western Scientists Look To Chinese Medicine For Fresh Leads. NPR, 18 Jan May < look-to-chinese-medicine-for-fresh-leads> Zhou, Guang-Biao, et. al. Retinoic Acid and Arsenic for Treating Acute Promyelocytic Leukemia. PLoS Medicine, Jan May 2014.