1. THE AMERICAN MEDICAL SYSTEM C. Antonio Jesurun, MD Professor Pediatrics

2. HEALTHCARE SPENDING US-$1.55 billion or 14% GDP US-$1.55 billion or 14% GDP Texas-$105.5 million or 11.7 % GSP Texas-$105.5 million or 11.7 % GSP

3. US HEALTHCARE SPENDING Hospital Care 36.5% Hospital Care 36.5% Physician & Other Professional Services 28.8% Physician & Other Professional Services 28.8% Prescription Drugs 12.2% Prescription Drugs 12.2% Nursing Home Care 7.4% Nursing Home Care 7.4% Dental Services 5.3% Dental Services 5.3% Home Health Care 2.8% Home Health Care 2.8% Other Medical Nondurables 2.1% Other Medical Nondurables 2.1% Medical Durables 1.5% Medical Durables 1.5% Other Personal Health Care 3.4% Other Personal Health Care 3.4%

4. US HEALTHCARE SPENDING Elementary & Secondary Higher Education Public Assistance Medicaid Corrections T ransportation All Other United States 35.7% 11.9% 2.3% 16.9% 7.0% 0.6% 25.6% Elementary & Secondary Higher Education Public Assistance Medicaid Corrections T ransportation All Other United States 35.7% 11.9% 2.3% 16.9% 7.0% 0.6% 25.6%United StatesUnited States Texas 41.3% 17.1% 0.9% 19.8% 10.9% 0% 10.1% Texas 41.3% 17.1% 0.9% 19.8% 10.9% 0% 10.1% Texas

5. Federal Poverty Guidelines United States Percent Under 100% 17% 100-199% 19% --Low Income Subtotal 36% 200% + 64% United States Percent Under 100% 17% 100-199% 19% --Low Income Subtotal 36% 200% + 64% United States United States TexasPercent Under 100% 22% 100-199% 21% --Low Income Subtotal 43% 200% + 57% TexasPercent Under 100% 22% 100-199% 21% --Low Income Subtotal 43% 200% + 57% Texas

6. HMO

7. PPO

8. Govenrnment Responsibilities Medicare Medicare Medicaid Medicaid SCHIP SCHIP SSI SSI VA VA Indian Health service Indian Health service GME GME

9. MEDICARE Over age 65 Over age 65 Legally Blind Legally Blind Certain Disabilities Certain Disabilities End-stage renal disease End-stage renal disease

10. MEDICARE Part A-Hospitalization Part A-Hospitalization –payroll taxes Part B-Physician’s fees & home health Part B-Physician’s fees & home health –Pay premium $78.20/month Part D-Drugs Part D-Drugs –Pay premium

11. ALL FEDERAL PROGRAMS Budget Budget Cost-control Cost-control

12. MEDICAID Low income families who have: Low income families who have: Pregnancy Pregnancy Disabilities-including blindness Disabilities-including blindness Children Children Eligibility set by state Eligibility set by state Different formulas/state/federal gov. Different formulas/state/federal gov.

13. MEDICAID

14. SCHIP Matching Federal/State funds Matching Federal/State funds Eligibility and benefits packages determined by each state Eligibility and benefits packages determined by each state Premium paid by family for children not eligible for medicaid Premium paid by family for children not eligible for medicaid

18. Terminology Disproportionate share funding (DSH) Disproportionate share funding (DSH) Upper payment level (UPL) Upper payment level (UPL) EMTALA EMTALA