The Healthcare Environment
Changes to Private Insurance (ACA)
-Require health plans to report proportion of premium dollars spend on care and provide rebates for amounts less than 80-85% -Establish process for reviewing increases in premiums -Provide dependent coverage up to age 26 -Eliminate lifetime limits on dollar value of coverage
Medicare (ACA)
-Restructure payments to Medicare Advantage Programs -Establish Independent Payment Advisory Board; submit proposals to reduce Medicare spending -Reduce payments to hospitals for excess readmissions -Reduce Medicare payments for hospital-acquired conditions by 1% (Falls, Hospital Acquired Infections)
Patient Protection and Affordable Care Act (PPACA, 2010)
-Signifies a comprehensive health reform effort to expand health insurance coverage, control healthcare costs, and improve healthcare delivery in the United States. -Includes fundamental changes to Medicare, expansion of the medicaid program, and reforms to part D, closing the Medicare donut hole by 2020. -Includes initiatives to prevent fraud and abuse; more health information technology; and promotes disease prevention programs across the healthcare system
Disease Management
System of coordinated health care interventions and communications for populations with conditions in which patient self-care is significant.
"Self Pay"
Uninsured
Premium Subsidies to Employers (ACA)
-Small business ( less than 25 employees with average wages less than 50,000) receive tax credits -Applies to tax years 2010 through 2013 -Tax credit up to 35% of employers contribution to health insurance premium -Tax years 2014 and beyond= up to 50% tax credits (if purchased through State Exchange) -Full credit for 10 or fewer employees lower paid employees
Financing ACA
-Congressional Budget Office estimates additional 32 million covered by 2019 -Estimates cost of coverage to be $938 billion over ten years. -Financed through taxes and fees -Estimates reduced federal deficit by $124 billion over ten years
Improving Quality/Health System Performance (ACA)
-Support comparative effectiveness research -Medical malpractice demonstration projects for alternatives to tort litigations -Medicare and Medicaid pilot program to explore bundling cost -Medicare Independence at Home demonstration project -Establish Medicare hospital value-based pay for performance program -Increase Medicaid payments for primary care services
Price Drivers in the U.S.
-Technology -Health status important; *obesity -Insurance administration cost -Excess capacity and low productivity -Higher prices for drugs (70% higher) -Aging Population
Value Metrics
-U.S. Infant Mortality Rate 7.0 per 1000 live births (2.7 in top 3 of 19 countries) -Preventive care in U.S.; adults 49% -Socioeconomic disparities in insurance, regular care, deaths for certain illness -Racial disparities for Hispanics and African Americans
Medicaid
-Administered by the state; sets own guidelines -Covers indigent, blind, disabled, disabled children -Funded by state funds (varies) and matching federal funds -Covers services provided by hospitals, physicians, laboratories, nursing home, home health, and prenatal care
Individual Mandate (ACA)
-All U.S. citizens and legal residents required to have health coverage -Tax penalties (phased in schedule) -Exceptions detailed
Technology Cost Control
-Appropriate application of medical technology to patients likely to receive the highest benefit -Reduce incentives that favor services incorporating new technologies -Increase use of consumer financial incentives and support; provide information on treatment alternatives and quality of different providers of care
Ways to Control Costs
-Capitation -Prospective Payment -Reduced Services -Public Information and Education -Risk Sharing
Medicaid (ACA)
-Changes to brand name drug rebates -Prohibit Medicaid payments for healthcare acquired conditions
Health Insurance Exchanges (ACA)
-Create state-based American Health Benefit Exchanges and Small Business Health Options Program (SHOP) Exchanges (States can purchase insurance for discounted rates) -Small businesses (up to 100 employees) and individuals can buy insurance -Four Benefit Tiers; Bronze through Platinum -Restrict to citizens and legal immigrants -Appropriate 4.8 billion to foster creation of non-profit member run health insurance companies -Qualifications of participating plans -Requirements of the exchanges -Permit states option to create a Basic Health Plan for uninsured with incomes 133-200% FPL -Permit states to prohibit plans in Exchange from providing coverage for Abortions (or separate premium) -Effective 2014
Expansion of Public Programs (ACA)
-Eligibility for Medicaid expanded to 133% FPL -Initially, more funding by federal dollars -Maintain income eligibility level for CHIP until 2019 -Extend funding for CHIP till 2015
Employer Requirement (ACA)
-Employers with 50 or more full time employees must provide insurance or pay penalty per employee -Penalty= 2,000-3,000 per employee (cheaper to pay penalty than provide insurance?) (Employers having more employees working part time to avoid having to provide)
Prevention/Wellness (ACA)
-Establish National Prevention, Health Promotion, and Public Health Council -Modifications to Medicare and Medicaid covered preventative services -Require chain restaurants and vending machine foods to disclose nutritional content
Other Investments (ACA)
-Establish Workforce Advisory Committee -Increase funding for primary care residency programs -Increase workforce supply; loans, scholarships, more... -Address projected shortage of nurses; FNP, more... -Increase funding for community and school-based health centers -Establish trauma care center program -Establish Regular Corps and Ready Reserve Corps for service in national emergency -Requirements for non-profit hospitals; community needs assessments, publicize financial assistance...more
US Department of Health and Human Services (HHS)
-Federal government's primary department for protecting the public's health and human services -Budget for fiscal year 2011 $911 billion; funds more than 300 programs and multiple agencies -Some of programs administered; Social Security, Medicare, maternal and infant health, prevention of child abuse and domestic violence and much more...
Cost Shifting
-Healthcare providers raise prices for the privately insured to offset the lower healthcare payments from Medicare and Medicaid, as well as the often nonpayment of healthcare premiums from the uninsured
Tax Changes Related to Health Insurance or Financing Health Reform (ACA)
-Impose tax on individuals without qualifying coverage ($695 per year or 3X that amount or 2.5% of income) -Exclude tax exemption for OTC drugs filed on FSA -Increase tax on distributions from HSA... -Limit flexible spending accounts to $2,500 per year -Increase threshold for itemized health deductions -Increase Medicare Part A taxes on wages by .9% -Impose excise tax on insurers of employer-sponsored health plans with higher coverage (40% tax). Also known as Cadillac Tax (effective 2018) -Impose new annual fees on pharmaceutical manufacturing sector ( 2.8 billion in 2012-2013 ) -Impose an annual fee on the health insurance sector (8 billion in 2014) -Impose excise tax of 2.3% on sale of any taxable medical devise -Impose 10% tax on amount paid for indoor tanning
Other Public Programs
-Indian Health Service -TRICARE -Veterans Health Administration
High Points of Affordable Care Act
-Individual Mandate -Employer Requirement -Expansion of Public Programs -Premium and Cost-Sharing Subsidies to Individuals -Premium Subsidies to Employers -Tax Changes Related to Health Insurance or Financing Health Reform -Health Insurance Exchanges -Changes to Private Insurance -Medicare -Medicaid -Improving Quality/Health System Performance -Prevention/Wellness -Long-Term Care -Other investments
Long-Term Care (ACA)
-Medicaid changes to enhance non-institutionally-based long-term care services -Establish national voluntary insurance program for purchasing community living assistance
Performance and Quality Measurements
-National Health Care Quality Report -Health Assessment Tools -Institute of Medicine Health Care Reports -Other National Public Quality Reports -Accreditation and Patient Safety -Health Professions Education -Quality and Safety Education for Nurses
Medicare
-Nations largest health insurance plan -Administered by the Centers for Medicare and Medicaid Services (CMS) -Covers those 65 and older; certain disabilities; and individuals with ESRD (>40 million enrolled) -Several Different Parts
Institute of Medicine (IOM)
-One of the national academies -"Advisors to the nation" -Shocked the nation in To Err is Human (1999) -Brought safety to the forefront???? -There are too many errors being made in healthcare
Private insurance employer based
-Premiums increased 114% between 1999-2007 and the increased cost is being passed to employees -Wage earnings increased 27% same period -Other factors to consider -Preexisting conditions -Denied claims -Preauthorization -Provider contracts with employers -Copays -Deductibles -Gaps still exist
Health Care and Education Reconciliation Act (HCERA, 2010)
-Product of the health care reform efforts -Financing and revenue changes to the PPACA -Divided into 2 titles, one addressing health care reform and another addressing student loan reform
Premium and Cost-Sharing Subsidies to Individuals (ACA)
-Provides premium credits to eligible individuals and families with incomes between 100-400% of FPL -Example: 100-133% FPL = 2% of income -Cost-sharing subsidies (increase value of benefits) -Must verify income and citizenship -Federal premiums and subsidies do not cover abortions
Per Capita
Dollars per person
Downstream Focus
Not spending money until the patient is already sick or injured
Deductible
A predetermined out-of-pocket fee paid by a patient for health care services before reimbursement through health insurance begins to be paid.
Healthcare Transparency
Ability to discover information about health care costs, medical errors, or practice preferences, preferably before receiving the service; also known as truth in reporting .
United States
Country that spends the most on healthcare and does not provide Universal Healthcare
Balanced Scorecard
Device used to monitor customer perspective; financial perspective; internal processes and human resources; and learning and growth (Kaplan & Norton, 2004) for strategic management and as a way to examine performance throughout the organization.
Medicaid
Established by Title XIX in 1965
Medicare
Established by Title XVIII in 1965
Co-payment
Fixed health care fee paid by the patient to the health care provider at the time of service; this amount is paid in addition to the money the health care provider will receive from the insurance company.
Disease Model
Focuses on curing illness and injury -Physicians
Medicare Part A
Hospital Insurance; hospitals, hospice, home health, SNCF (funded through Social Security Taxes)
Downstream
Is money going upstream or downstream?
Medicare Part B
Medical Insurance; covers physician services, outpatient care, medical equipment, and diagnostic tests (funded through federal taxes and monthly premiums paid by recipients) optional
Public Government
Provide healthcare programs such as Medicare, Medicaid, SCHIP, ect.
Process
Set of causes and conditions that repeatedly come together in a series of steps to transfer inputs into outcomes.
Technology
The key driver of healthcare spending
Disproportionate Spending
The majority of the money is being spent on a small percentage of the population. -This percentage are patients who are chronically ill with expensive needs (increased technology needs)
Gross Domestic Product
The sum of the outputs of every class of enterprise (expressed in trillions).
Texas
This state has one of the highest rates (16.4%) of uninsured children in the United States
Payers/Insurance in Canada
everyone pays premiums to government
Payers/Insurance in Great Britain
government taxes pay for everything (taxes are extremely high)
For Profit Organizations
have investors and make a profit margin that goes back into the investors pocket
Upstream Care
health promotion and illness prevention -Potential opportunity for nurses
Medicare Part D
optional coverage for outpatient medications
Payers/Insurance in Germany
private insurance, with premiums split employers/ workers
Non-Profit Organizations
provide service and make no profit
Capitation
the payment of a fixed dollar amount, per person, for the provision of health services to a patient population for a specific period of time