Health Care in the US

Main factors that limit the patient's ability to make health care purchase decisions

-circumstances surrounding sickness and injury often prohibit comparative shopping based on price and quality -such information is not easily available -decisions about utilization of health care are often determined by need rather than by price-based demand -provider based demand

what made the divide between public health and private medical practice? 3

-fear of government intervention -loss of autonomy -erosion of personal incomes

types of private insurance

-group insurance -self insurance -individual private health insurance -managed care plans -high deductible health plans

leading causes of death

-heart disease -cancer -cerebrovascular diseases -chronic lower respiratory diseases -unintentional injuries

most common types of chronic diseases

-hypertension -cholesterol disorders *for younger ppl: -asthma -respiratory disorders

why did the medical profession remain largely an insignificant trade in the preindustrial era? 5

-medical practice was in disarray -medical procedures were primitive -an institutional core was missing -demand was unstable -medical education was substandard

post industrial healthcare vs preindustrial

-more sophisticated medicine -organized medical profession

natality vs fertility rate

-natality rate: number of live births/total population -fertility rate: number of live births/number of females aged 15-44 *fertility rates are more precise because they relate actual births to the sector of the population capable of giving birth

why the rise of chronic conditions in the US?

-new diagnostic methods, medical procedures, and pharmaceuticals -lifestyle choices- diets, sedentary lifestles

why did self insurance come about

-self insured employers were exempt from a premium tax that insurance companies had to pay -also, Employee Retirement Income Security Act (ERISA) exempts self-insured plans from certain mandatory benefits that regular health insurance plans are required to provide in many states

factors that contributed to the professionalization of the medical profession 7

-urbanization -science & technology -institutionalization -dependency -cohesiveness and organization -licensing -educational reform

AMA wasn't too thrilled about the ACA (wanted to maintain it's tiny monopoly over the medical coding system that health care providers must use to get paid)

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An acceptable healthcare delivery system should have 2 primary objectives:

1. It must enable all citizens to obtain health care services when needed 2. the services must be cost effective and meet certain established standards or quality

Beliefs in American culture (5)

1. a strong belief in the advancement of sciences and application of scientific methods to medicine were instrumental in creating the medical model that primarily governs health care delivery in the US- medical model has fueled tremendous growth in medical science and technological innovation, which has been leading the world in medical breakthroughs- [however, this as many implications: increase demand for latest treatment, medical professionals have been preoccupied with clinical interventions, not holistic medicine, hospitals valued for amount of technology, few attempts made to integrate diagnosis and treatment with health education and disease prevention 2. America= champion of capitalism- due to strong belief in capitalism, health care has largely been viewed as an economic good, not a public resource 3. culture of capitalism promotes entrepreneurial spirit/ self-determination, so individual capabilities to obtain health services determine who gets access, which services will be produced, etc (health care= social privilege, fosters individual vs population health) 4. a concern for the most underprivileged classes in society led to creation of Medicare/caid and CHIP 5. principles of free enterprise and a general distrust of big government have kept health care delivery in private hands

Employed ppl may not have health insurance coverage for 2 main reasons:

1. in most states, employers are not mandated to offer health insurance to their employees 2. In many work settings, participation in health insurance is voluntary and does not require employees to join. - some ppl still just cant afford it

10 basic characteristics of US healthcare system (different from other countries)

1. no central agency governs the system 2. access to health caree services is selectively based on insurance coverage 3. health care is delivered under imperfect market conditions 4. third party insurers act as intermediaries between the financing and delivery functions 5. the existence of multiple payers makes the system cumbersome 6. The balance of power among various players prevents any single entity from dominating the system 7. Legal risks influence practice behavior of physicians 8. development of new technology creates an automatic demand for its use 9. new service settings have evolved along a continuum 10. quality is no longer accepted as an unachievable goal in the delivery of health care

who can have access to health care in US (4)

1. people who have health insurance through their employers 2. covered under government health care program 3. can afford to buy insurance with own private funds 4. are able to pay for services privately

four fundamental principles underlie the concept of insurance

1. risk is unpredictable for the individual insured 2. risk can be predicted with a reasonable degree of accuracy for a group/population 3. insurance provides a mechanism for transferring/shifting risk from the individual to the group through the pooling of resources 4. all members of the insured group share actual losses on some equitable basis

3 main factors explain how health insurance in the US became employment based

1. to control high inflation in the economy during WWII, Congress imposed wage freezes. In response, many employers started offering health insurance to their workers in lieu of wage increases 2. in 1948 Supreme Court rules that employee benefits, including health insurance, were a legitimate part of the union-management bargaining process 3. employer contributions for the purchase of employee health insurance became exempt from taxable income for the employee (in other words- employees could get noncash income without having to taxes on this income)

Healthy People Initiatives

10 year plans outlining certain key national health objectives to be accomplished during wach of the 10 year periods -newest Health People has more of an emphasis on the determinants of health, also more of an emphasis on adolescent health, genomics, global health, health communication, and health information technology

__% of total health expenditures in the US are attributable to the treatment of chronic conditions

75%

The Homeland Security Act of 2002 signed into law in Nov 2002 by the Bush Administration, created..?

Department of Homeland Security- called for major restructuring of the nation's resources with the primary mission of helping prevent, protect, against, and respond to any acts of terrorism in the US

Premium cost sharing

Employers pay part of employees premium

blueprint for modern health insurance established by___ at ___ university

JF Kimball, Baylor University -it was a plan in which teachers would pay $0.50 a month for maximum 21 days hospital care. Within a few years, it became the model for Blue Cross plans across the country

managed care plans

MCOs such as HMOs and preferred provider organizations (PPOs) emerged in response to the rapid escalation in health care costs- managed care plans are a type of health insurance because they assume risk in exchange for an insurance premium- but it's more than just insurance. MCOs provide a broad range of services generally emphasizing primary and preventive care

The gov finances public insurance through these 3 organizations

Medicare, Medicaid, CHIP

packaged pricing

a bundled fee for a package of related services

pre-paid plan

a contractual agreement under which a provider must provide all needed services to a group of members in exchange for a fixed monthly fee paid in advance

epidemic

a large number of people who get a specific disease

Managed care def

a system of health care delivery that 1. seeks to achieve efficiencies by integrating the 4 functions of healthcare delivery (financing, insurance, delivery, payment), 2. employs mechanisms to control utilization of medical services, and 3. determines the price at which the services are purchased, and consequently, how much the providers get paid

underwriting

a systematic technique for evaluating, selecting (or rejecting), classifying, and rating risks

one of the most widely used measures of physical disability among the elderly is:

activities of daily living- ADL- which includes 6 basic activities to determine whether an individual needs assistance

primary prevention

activities undertaken to reduce the probability that a disease will develop in the future

prepaid group plans

an enrolled pop received comprehensive services for a capitated fee

pesthouse

another house of preindustrial era- quarantined people who had contagious diseases

market justice

ascribes fair distribution of health care to the market forces in a free economy- the free market implies that giving people something they have not earned would be morally and economically wrong

Medicare allowed physicians to _____ _______, that is. charge the patient the amount above the program's set fees and recoup the difference. Does Medicaid do this?

balance bill Medicaid prohibits balance billing, causing a 2 tiered system of medical care delivery bc some docs don't accept Medicaid patients due to low fees set by the government

determinants of health

biology, genetics, individual behavior, access to health services, and the environment in which people are born, live work, and age

group practice

brought docs together with business managers - multispecialty group

contract practice

capitation- they (company) contracted w docs at flee fee per month

health plan

collective array of covered health services that the enrollee is entitled to

high deductible health plans

combine health insurance with a savings option- so basically people pay a high deductible up front with lower monthly premiums. Then they can open up a tax free account called a health savings account or HRA that they can use to put in money for future medical expenses and their employer can also contribute money to it

prototypes of managed care (3)

contract practice, group practice, prepaid group practice

capitation

contracting with independent docs and hospitals at a flat fee per worker per month

Medicare Part B

covering physician's bills through gov subsidized insurance

Medicare Part A

covers hospital care and partial nursing home coverage for elderly

provider based demand

docs have a huge influence on the demand for health care services- some docs create demand for their own financial benefit

Blue Shield pays for

doctors' bills

almshouse

during the preindustrial era of American hospitals- almshouses served primarily the poor- generally provided food and shelter to the destitute and the ill were also cared for

secondary prevention

early detection and treatment of disease

For most privately insured Americans, health insurance is ____-based

employer-based

4 main determinants of health

environment, lifestyle, heredity, medical care

2 methods used to determine premiums (what are they)

experience rating- based on a group's own medical claims experience- under this method, premiums differ from group to group because diff groups have diff risks (higher rates for sicker ppl) community rating- spreads the risk among members of a larger community and establishes premiums based on the utilization experience of the whole community (same rate applies to everyone regardless of age, gender, or health risk)

Health care is a mix of 4 basic functional components:

financing, insurance, delivery, payment

group insurance

group insurance- anticipates that a substantial number of people in the group will purchase insurance through its sponsor, risk is spread out among the insured individuals

Effect of the consolidation of buying power in the hands of private health plans

has been forcing providers to form alliances and integrated delivery systems on the supply side (networks of health services organizations)- this is bc they are making HMOs and stuff with networked providers

what does the consolidation of patients into health plans do?

has the effect of shifting the power from the patients to the administrators of the plans (bc patients cant negotiate based on price of services)- prices are determined by the payers- such as managed care, Medicare, Medicaid. Because prices are set by agencies external to the market, they are not government by the unencumbered forces of supply and demand

WHO's def of health

health is a state of complete physical, mental, and social wellbeing and not merely the absence of disease/infirmity

medical model's definition of health

health is the absence of illness/disease

Blue Cross pays for

hospital care

immigration vs emigration

immigration- in migration, emigration- out migration

cost sharing

in addition to paying a share of the cost of premiums through payroll deductions, insured individuals, as well as those participating in certain public insurance programs, pay a portion of the actual cost of medical service out of their own pockets in the form of deductibles and copays

technically, health insurance plans can be classified as either____ or ____ plans

indemnity or service

individual private health insurance

individually purchased private health insurance (nongroup plans) = coverage for so Americans

_____ is the main factor that determines the level of demand for health services

insurance

tertiary prevention

interventions that could prevent complications from chronic conditions and prevent further illness, injury, or disability

market based vs social justice based rationing

market based- demand side rationing- limiting demand of health care services (dont have to limit health care services, limit the demand for them so only the most well off can get them) social justice- supply side rationing- meaning they have to limit the supply of resources so that everyone gets some

despite the fact that medical care, compared to the other three factors, has the least impact on health and well-being, Americans; attitudes toward health improvement focus more on-

medical research, development of new medical technology, the spending more on high-tech medical care. Yet, significant declines in mortality rates were achieved well before the modernization of Western medicine and the escalation in medical care expenditures (meaning, it would also be beneficial to look at environment, lifestyle, etc)

stop loss provision

most plans include this- it is the maximum out of pocket liability an insured could incur in a given year

moral hazard

once enrollees have purchased health insurance, they will use health care services to a greater extent than if they were to bear the full cost of these services "health care has the effect of insulating patients form the full cost of health care"

As opposed to many European countries, the US has mainly a ____ system of financing (percentage)

private, 54%

indemnity plans

provides reimbursement to the insured, without regard to the expenses actually incurred (basically, a predetermined cash amount is paid to the beneficiary per procedure or per day in the hospital. The insured is responsible for paying the provider- no relationship between insurance company and the provider)

service plans

provides specified services to the insured. The plan pays the hospital or physician directly, except for deductible/copays

utilization

quantity of healthcare consumed

early hospitals- conditions

really gross, people called them houses of death because it was so easy to die in them

crude mortality rates

refer to the total population- not specific to any age group

how to self insured employers protect themselves against the potential risk of high losses?

reinsurance- from private insurance company

The Flexner Report

report that investigated medical schools and decided which schools met the proposed standards

gatekeeping

something that the US implemented as late as the 1990s- it requires initial contact with a generalist doc and a generalist's referral to a specialist

standards of participation

standards set by US government that providers must comply with to be certified to provide services to Medicaid, CHIP, and Medicare

premium

the amount charged by the insurer to insure against specified risks

deductible

the amount the insured must first pay before any benefits are payable by the plan (paid on annual basis usually)

copayment

the amount the insured must pay each time health services are received

social justice

the equitable distribution of health care is a societal responsibility, which is best achieved by letting a central agency- the government- take over the production and distribution of health care. Health care is governed by need, not by ability to pay

fee for service

the practice of billing separately for each individual type of service

HIPAA of 1996 made what illegal?

the practice of excluding coverage to people w preexisting conditions

How do Medicare and Medicaid recognize beneficiaries vs as opposed to employer based plans?

they recognize only on the individual basis- so like a married couple Medicare/caid recognize each spouse as an independent beneficiary

what is the rationale for cost sharing?

to control the utilization of health care services

In 2006, Bush signed the Pandemic and All-Hazards Preparedness Act, which did what

to improve the nation's public health and medical preparedness and response capabilities for emergencies, whether deliberate, accidental, or natural

coinsurance

type of copayment but it's a percentage of the cost of the medical service

difference between group insurance and individual private insurance

unlike group insurance, which spreads risk over the entire group, individual health insurance determines premium price and eligibility based on health status risk -premiums much higher in individual

difference between health insurance received from the employer and regular wages

unlike monetary wages, health insurance benefits are not subject to income tax. Consequently, a dollar of health insurance received from the employer is worth more than the same amount received in taxable wages or an after tax dollar spent out of pocket for medical care (more bang for your buck

American Association of Labor Legislation AALL

wanted a model for national health insurance

capitation

when all health care services are included under one set fee per covered individual

balance bill

when only partial payment is received, some health plans may allow the provider to balance bill the patient for the amount the health plan did not pay

cost shifting

when private payers are charged more to make up the difference when insurance doesn't cover it all

self insurance

when the employer acts as its own insurer- rather than pay insurers a dividend to bear the risk, large employers can simply assume the risk by budgeting a certain amount to pay medical claims incurred by their employees

Who are the ppl that are most disenfranchised in the US?

working ppl earning low wages bc they're not eligible for public benefits and cant afford the premium cost sharing