Chapter 9
Government/public health insurance
-The Medicare Program -The Medicaid Program -Military Health System -The Children's Health Insurance Program (CHIP) -Individual state health plans
Government/Public Insurance:
-The two major public health insurance plans in the United States are Medicare and Medicaid -Workers' compensation pays benefits to workers who have been injured on the job -The Children's Health Insurance Program (CHIP) provides health coverage to uninsured children
Efforts at Cost Containment: Characterized by three trends-
-There is a move away from traditional fee-for-service to newer models of managed care -Companies are attempting to manage health care of their employees themselves -Moving to self-insured plans -Payers (government, insurance, employers) are setting reimbursement restrictions and limitations-
Private Insurance: POSs
-Allow members to get medical care from both in-network and out-of-network providers -Encourage selection of a PCP from a list of participating providers; require a referral to visit an out-of-network provider
Cost-Effectiveness of Nutrition Services
-Care delivered according to detailed guidelines for care (protocols) has been linked with positive outcomes for the patient -Protocols that produce positive outcomes should include cost-effectiveness information -All practitioners should document cost-effectiveness of their nutrition programs
Three interrelated variables in rating a health care system:
-Cost -Quality -Access Manipulating one has an astounding impact on the others
Affordable Care Act 2010
-Reduces number of people who are uninsured -Makes health insurance system work better for all consumers -Transforms delivery and payment systems to get better value -Reorients focus to prevention and primary care
Government/Public Insurance: Coverage gaps-
-prescription drug coverage and skilled nursing/long-term institutional care -Medigap policy from private insurance companies -Medicare, Part C
Most industrialized countries except the U.S. have national health care programs
-Coverage is universal -Coverage is uniform -Costs paid by tax revenues or by combination of individual/employer premiums and government subsidization
The pluralistic system of health care in the United States
-Employment-based private insurance -Direct-purchase private insurance -Medicare, Medicaid, workers' compensation -The Veterans Health Administration medical care system -The Department of Defense hospitals and clinics, the Public Health Service's Indian Health Service -State and local public health programs -The Department of Justice's Federal Bureau of Prisons
Private Insurance: PPOs
-Enter into agreements with health care providers -Do not require members to select a PCP -Have lower charges to members if they use an in-network provider
Private Insurance: HMOs
-Groups of physicians share facilities and medical records -Fixed cost to the consumer, usually with monthly premiums and co-payments for medical visits -May or may not provide reimbursement for dietitian's counseling -Emphasize health promotion
The scope of dietetics practice includes:
-Nutrition assessment -Nutrition counseling and education -Research, development, and evaluation of appropriate nutrition practice guidelines -Administration through management of time, finances, personnel, protocols, and programs -Consultation with patients, clients, and other health professionals -Evaluation of the effectiveness of nutrition counseling/education and community nutrition programs
Private Insurance: Consumer-directed health plans
-Plans combine a high-deductible health plan (HDHP) with a tax-advantaged health reimbursement arrangement (HRA) or health savings account (HSA) of their health expenses -Enrollees use a HSA to pay for a portion of their expenses -Proponents contend that enrollees seek lower-cost care and seek care only when necessary -Critics state that employers may use these to shift cost of coverage to employees
Private Insurance: EPOs
-Plans generally limit coverage to care from providers (doctors, specialists, or hospitals) in the plan's network
Medical Nutrition Therapy and Medicare Reform
-Since 1992 legislative priority of the Academy has been inclusion of medical nutrition therapy as covered benefit in health care delivery -Focus is on securing reimbursement under existing federal insurance programs -MNT now covered under Part B for selected Medicare recipients -Study by the Academy has shown projected savings in medical costs if all Medicare recipients were to receive MNT -Greatest cost-effectiveness is for MNT coverage for recipients with diabetes and cardiovascular disease
Government/Public Insurance: Health care services are also provided by-
-The Department of Veterans Affairs (VA) -The Public Health Service (including the Indian Health Service) -The Department of Defense (including TRICARE) -Public hospitals and community health centers -State and local public health programs
Future Changes in Health Care and its Delivery
-The paradigm shift from sickness to wellness will be one of the strongest factors affecting health care -Medical education will have to change -Health care must change from a system based on treatment of acute conditions to disease prevention and health promotion -Nutrition services must be part of preventive care -Community nutritionists need to educate payers of health care about value of including nutrition services in their policies -Begin with local advocacy and persistence
Efforts at Cost Containment: Prospective Payment System (PPS):
-Uses diagnosis related groups (DRGs) as a basis for reimbursement -Patients classified according to principal diagnosis, secondary diagnosis, age, sex, and surgical procedures -All DRGs have been assigned a relative weight reflecting cost of care -Has resulted in increased focus on outpatient services (preventive medicine) which are less costly than inpatient care
Private Insurance: Indemnity or traditional fee-for-service plans -
-charges for each service rendered -Accounts for only a small percentage of insurance coverage today -Proponents prefer the greater flexibility and unrestricted access health care providers and facilities -Critics claim that fee-for-service plans encourage physicians to provide unnecessary services
Government/Public Insurance: Medicare
-federally run program for persons over age 65, or in other eligible categories Part A - hospital insurance; inpatient care -Deductible and coinsurance fees apply -Long-term care -100 days covered annually Part B - optional medical insurance; outpatient care -Supplementary medical insurance benefits for eligible medical expenses
Government/Public Insurance: Children's Health Insurance Plan (CHIP) -
-for children in families with income above poverty level but too low to afford private health insurance -Partnership between federal and state governments -Includes inpatient and outpatient services, laboratory, and x-ray -Well-baby and child care services -Medications, vision care, and hearing-related care
Private Insurance: Managed-care insurance -
-insurers try to limit the use of health services, reduce costs, or both Represented by: -Health maintenance organizations (HMOs) -Preferred provider organizations (PPOs) -Point-of-service plans (POSs) -Exclusive provider organizations (EPOs) -Presumed goal of managed care - improved quality of care with decreased costs -Accounts for around 99% of coverage for employees
Government/Public Insurance: Medicaid-
-joint state and federal program for low-income persons, the aged, blind, and disabled, dependent children of one-parent families -Income must be below 133% of poverty line -Covers inpatient and outpatient hospital services, physician, laboratory and x-ray, skilled nursing home, home health services
Demographic Trends and Health Care
Baby boomers make up more than one-fourth of the populatiom -By 2030, 21% of population will be over 65 -Demand for care can be expected to rise
The High Cost of Health Care:
In the U.S., $2.9 trillion spent on health care services and products in 2013 Major contributors: -Administration of insurance process -Practice of defensive medicine -Professional liability costs
Uninsured-
Working poor and self-employed, early retirees, unemployed -Represent 13% of all Americans -Use hospital emergency room care -Often delay getting treatment and later require more expensive medical services
Racial and geographic factors are important considerations:
-Hispanic population will increase -Population drift from Northeast to Southwest and Sun Belt
Private health insurance
-Indemnity or traditional fee-for-service insurance -Managed-care insurance -Consumer-directed health plans
Racial and ethnic disparities in health
Healthy People 2020 has focused on achieving health equity, eliminating health disparities, and improving the health of all groups
