PUBH6012

cherry picking

Targeting the enrollment of healthy patients to minimize healthcare costs.

How is our system different from other OECD countries in terms of: Costs

U.S. stood out as a top consumer of sophisticated diagnostic imaging technology and prescription drugs

Market failure

When resources are not allocated efficiently When it occurs, the question is what intervention, if any, should occur to correct the market failure? What about equity?

ACA market places: -what are they?

a place to select an ACA compliant coverage plan specific to your state

asymmetric information

a situation in which one side of the market has more reliable information than the other side insurance company negotiates with employer so they don't know what individuals need

cost sharing

a situation where insured individuals pay a portion of the healthcare costs, such as deductibles, coinsurance or co-payments

co-insurance

a type of insurance in which the insured pays a share of the payment made against a claim. %

-based on what attributes can ACA plans can vary insurance premiums under a plan

age, geographic area, family composition, and tobacco use

State/centralized

all local health departments are units of state government, which makes most fiscal decisions

supply

amount of goods or services that producers are willing and able to sell at a given price over a given time

deductibles

amount of money you owe out of pocket before your insurance kicks in

-metal level

are based on how you and your insurance plan split costs. Categories have nothing to do with quality of care

-what does the difference between the Bronze, Silver, Gold, and Platinum plans reflect?

bronze: 60% actuarial value silver: 70% gold: 80% platinum: 90% plans must offer at least one silver-level and one gold-level option in each exchange in which they participate

Common safety net providers include

community health centers and rural health clinics, some public and private hospitals, local public health agencies (i.e. STD screening), and some private providers (i.e. St. Jude's)

What are the attributes of managed care?

comprehensive defined package of benefits to the purchaser for a preset fee. services are offered through a network, use financial incentives to control costs

Demand changers

consumers income, quality, price of substitute, price of complements

efficient distribution

distribution of resources cannot be changed to make someone better off without making someone else worse off

-the coverage gap

donut hole Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means there's a temporary limit on what the drug plan will cover for drugs. Not everyone will enter the coverage gap.

ACA market places: how much variation is there in choice of plans depending on location

each state has a marketplace that must have at least 2 plans available

-the family affordability glitch

employee affordability is based on self-only coverage costing less than 9.5% of income. family plans are more expensive but if the self only coverage is "affordable" then the family is not eligible for subsidies

How is it set up? Main components?

it is a mix of an entrepreneurial system, welfare-oriented system (Medicare), single payer system (Medicaid), and comprehensive system (Veterans Health Administration) it has a mix of public and private funding public = Medicare, Medicaid, and CHIP private = majority of financing in the US; private insurance companies

Local/decentralized

local health departments are units led by local governments, which make most fiscal decisions

How does managed care differ from traditional insurance?

managed care replaced fee for service system which did not incentivize providers to utilize healthcare services sparingly so healthcare costs were really expensive

premiums

membership fee for insurance

ACA marketplaces: -what must all ACA compliant plans offer?

must offer a standard benefits package including: Ambulatory patient services Emergency services Hospitalization Maternity and Newborn care Mental health services Prescription drugs Rehabilitative services Lab services prevention and wellness Pediatric services

-Main issue in Texas vs Azar Supreme Court Case

since mandate was set to zero then it was no longer a tax so the rest of the ACA should no longer stand. intervener states says that mandate is severable. will go to the fifth circuit of appeals and on to the supreme court.

supplier induced demand

the amount of demand that exists beyond what would have occurred in a market in which patients are fully informed

Actuarial Value

the average share of covered benefits generally paid by the insurer based on the cost-sharing provisions in the plan

Seld insured

(or "self-funded") group health plan: The employer assumes financial risk of paying for health care benefits to its employees. Self-insured employers pay for each claim as they are incurred. Usually set up a trust fund to earmark money to pay claims. May purchase insurance against exceeding amount available to pay claims (reinsurance). Self-insured employer may contract with an insurance company to act as a "third-party administrator" (TPA) to administer the health plan for that company, sometimes using its existing networks and relationships.

What are the powers of the federal govt

- Limited to those specifically enumerated (Tenth Amendment) - Tax o Raise revenue o Regulate private activities by influencing economic decision making - Spend o Allocate resources o Set conditions for receipt of funds o Regulate private activities by influencing economic decision making - Regulate interstate commerce o Expansive power § Not solely intrastate § Can't excessively intrude on state sovereignty or limit state sovereign immunity

What are the powers of the state govt

- Police powers o To act to promote health, safety, morals, and general welfare of the people o Power to restrict individual liberty and economic interests - Create state health departments and agencies - Tax and spend - Licensing and regulation (providers, insurance) - Create sub-units o Delegate power

Purpose of public health

- Prevent epidemics and spread of disease - Protect against environmental hazards - Prevent injuries - Promote and encourage healthy behaviors - Respond to disasters and assist communities in recovery - Assure the quality and accessibility of services.

What accounts for these spending differences?

- Price variability coupled with lack of price transparency - Cost of medical errors - Excessive testing - "best" technology

How does the federal government influence what happens in states?

- Tax policy - Setting federal budgets - Grants, incentives and federal aid

-Outcome of Supreme Court Case NFIB vs Sebelius

1) Individual mandate not constitutional based on interstate commerce but constitutional as a tax. 2) Medicaid expansion was coercive so it became optional

How much is US total health care spending annually in $? As a percent of GPD? Per capita? And, how do the latter two compare with other OECD countries?

3.5 trillion dollars in 2017, 17.9% GDP, we spend 2x more than other OECD countries and have worse outcomes

Elasticity

A measure of how much one economic variable responds to changes in another economic variable.

ACA market places: -what is an ACA-compliant plan?

ACA-compliant refers to a major medical health insurance policy that conforms to the regulations set forth in the Affordable Care Act (Obamacare).

Shared

All local health departments are governed by both state and local authorities.

ACA market places: -who can purchase insurance there?

Any legal resident except those incarcerated

What are the core functions of our public health system?

Assessment Policy development Assurance

Health economics

Branch of economics concerned with the problems of producing and distributing the health care resources of the nation in a way that provides maximum benefit to the most people. Application of microeconomic tools to health issues and problems Study of societal allocation of scarce resources for health care

Where do local powers come from?

By the state

Short-term health insurance

Can only be purchased for a specific period of time. • Just stop gap, limited benefits; not qualifying coverage

Moral hazard

Concept that if health care is less expensive (to me), I'll use more and may be less likely to take action to avoid using it

What is EMTALA? In what way is it considered a "true right to health care"? Do you agree?

Emergency Medical Treatment and Labor Act (EMTALA) is a federal law that requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay It requires hospitals that participate in Medicare that have an emergency department to screen and stabilize anyone who comes to the ED. No because the hospital can then either admit them as an inpatient to treat them, or they can transfer them to another hospital. So it does not require-- and this is a myth. It does not require hospitals to give free care to anybody who comes to the ER. It doesn't require a hospital even to treat everyone that comes to an ER. It only requires them to screen and stabilize the emergency condition.

What are the powers of the local government

Enforce state and local laws Promote public health Protect public safety Educate children Protect the Environment Regulate land use Collect Taxes Immunizations not covered by private insurance, communicable disease surveillance, communicable disease control, Inspection of restaurants, Environmental health surveillance, public health screening, tobacco control, public health preparedness and response to disaster

co-payments

Fixed fee that is paid by the patient at each office visit

What is the main way in which PPOs, POS plans, and HMOs differ (on a continuum)?

HMO provides coverage only if members seek care from network providers and providers may or may not be limited to only serving HMO members PPOs have provider network but unlike HMO PPOs provide coverage to patients seeking care from any provider even out of network POs designated services may be obtained from out-of-network providers who are paid on an FFS basis

HIPAA

Health Insurance Portability And Accountability Act of 1996 (HIPAA) Created first national standards regarding portability and accountability • Reduce risk segmentation • Reduce access barriers due to health status Guaranteed access and renewability Portability • Prevent "job lock" • Limit preexisting condition exclusions Information privacy and security regulations

What are the two major kinds of managed care plans?

Health Maintenance Organizations (HMOs), Preferred Provider Organizations

What are the pros and cons of managed care from the public health system perspective?

Health System: pros: incentives for reduced unnecessary care, may lower costs, quality improvement cons: concerns about quality, barriers to necessary care

Judicial "power levers"

Judicial review - decide if constitutional

Legislative "power levers"

Lawmaking body of the federal government. Congress has power to levy taxes, collect revenue, pay debts, provide for general welfare, regulate interstate and foreign commerce, establish federal courts inferior to the Supreme Court and declare war. The Senate has the specific power to ratify treaties and confirm nominations of public officials.

How do states push back? Enlist help? Etc.

Lawsuits

Managed care

Managed care plans are a type of health insurance. They have contracts with health care providers and medical facilities to provide care for members at reduced costs. These providers make up the plan's network (HMO, PPO, POS)

benefit package

Medical necessity Mandates Limits (example: annual benefit limit, lifetime limit)

What are the pros and cons of managed care from the member perspectives?

Member: pros: more plan choices fro employees, may lower costs, quality controls, coordinated care, comprehensive benefits cons: reduced choice of providers, concerns about the quality of care, increased cost of provider

Is healthcare perfectly competative?

No - not a perfectly competitive market

Public goods

Non-rival: more than one person can enjoy simultaneously Nonexclusive: impossible or too costly to exclude individuals from enjoying the good Examples: national defense, lighthouse

Who are the uninsured?

Poor Workers in low-paying jobs Certain job sectors Small firms, non-unionized, low-pay, retail/sales, part-time, agriculture, construction, fishing, mining, self-employed Young adults Lesser educated Minorities Men (because Medicaid was not available before ACA) Residents of the South and West

Externalities

Positive or negative impact when one person's actions create a benefit of imposing a coston others - Herd immunity/not getting vaccination - Mosquito abatement - Hazardous waste disposal - Pollution

Executive "power levers"

President can: agenda setting, power to veto bill, executive order given to federal agencies, Admin agencies: does the nitty gritty of implementing laws

supply changers

Price of good Input costs Number of sellers Change in technology

What are the pros and cons of managed care from the provider perspectives?

Provider: pros: coordinated care, salary, financial incentives cons: concerns about barriers to care, interference with provider relationship

What are the consequences of being uninsured?

So the consequences of being uninsured are not just that some individual person might have expenses that they have to pay-- later high expenses where they might have trouble paying. It really has consequences for everybody else in the economy as well. And it also leads to people consuming health care in the most expensive and least efficient place, which is the emergency room.

Mixed

Some local health departments are led by state government, and some are led by local government. No one arrangement predominates in the state.

Where do state powers come from?

State powers come from the Constitution. More specifically, the 10th amendment, which says powers not delegated to the US by the constitution nor prohibited by it to the States, are reserved to the States respectively, or the people.

-market place

The Health Insurance Marketplace is a platform that offers insurance plans to individuals, families, and small businesses. where goods and services are sold

How is our system different from other OECD countries in terms of: Outcomes

The US far exceeds spending compared to that of other high-income countries, but the US still sees poorer results on several key health outcome measures such as life expectancy and prevalence of chronic conditions

How is our system different from other OECD countries in terms of: Structure

The US is also the only of these countries that do not have a universal health care system, and thus covers fewer residents. We also spend less on social care

Where do federal powers come from?

The constitution

Fully insured group health plan

The employer pays premium to insurance company; insurance company pays the claims of employees per contract with employer.

Why are they uninsured?

Their employment doesn't provide coverage, illegal immigrants, too poor etc.

government intervention

gov directly provides goods, gov finances provision of goods, taxes or subsidies

free rider

people enjoy w/o paying and it is too costly to exclude them

Supply elasticity

percentage change in quantity supplied resulting from a one-percent increase in price of buying the good

Demand

quantity of goods and services that a consumer is willing and able to purchase over a specific time

What is the "Safety Net" and what sorts of entities comprise it?

those who serve disproportionately high numbers of uninsured and publicly insured (Medicaid/CHIP), and serve them regardless of patient's ability to pay

What populations does the safety net serve?

uninsured and publicly insured (Medicaid/CHIP)

adverse selection

when you have too many sick people in the risk pool and not enough healthy people to spread out risk

High-deductible health plan (HDHP)

• Features higher deductibles than traditional insurance plans (sometimes as high as $10,000); can be combined with a health savings account or a health reimbursement arrangement to allow you to pay for qualified out-of-pocket medical expenses on a pre-tax basis

What HIPAA doesn't do:

• No protections from individual plan to individual plan • No protections if you are uninsured • Limited protections without continuous coverage • No limits on premiums or other health insurance costs • Does not require employers to offer health insurance • Or offer family or dependent coverage • Does not require certain set of benefits to be provided

What are the salient features of our health care system?

• Provide personal medical care, particularly acute, curative services, but also prevention and longer-term therapies • Be part of the public health response and coordinate health promotion and prevention • Collaborate with other sectors in the economy, such as education, housing, transportation, water and sanitation, and labor

Catastrophic plan

• Type of HDHP with high deductible and limited benefits (allowed under ACA for under 30s in exchange with some preventive care, not full minimum benefits)