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U.S. Healthcare
And God populated the earth with broccoli and cauliflower and spinach and green and
yellow vegetables of all kinds, so man and woman would live long and healthy lives.
And Satan created McDonald's.. . .
And God created the healthful yogurt, that woman might keep her figure that man
found so fair.
And Satan froze the yogurt, and he brought forth chocolate, nuts and brightly colored
sprinkle candy to put on the yogurt....
And God brought forth running shoes....
And Satan brought forth cable TV with remote control....
And God brought forth the potato....
And Satan peeled off the healthful skin and sliced the starchy center into chip and
deep-fat fried them....
And Man clutched his remote control and ate the potato chips....
And Satan saw and said, "It is good.“
And Man went into cardiac arrest.
And God sighed and created quadruple bypass surgery.
And Satan created the HMO.
Jonas S, 2003
U.S. Healthcare
Objectives
•
Review the Economic Trends of 2003
•
Review the components of Health Care
•
Compare Health Insurance Plans
•
Discuss current issues in health care coverage and
insurance
National health spending growth is projected to significantly increase as a
share of GDP over the next decade.
NHE
Projected NHE
GDP Share
$3,000
Projected GDP Share
Projected
Actual
18%
16%
$2,500
14%
12%
10%
$1,500
8%
$1,000
6%
4%
$500
2%
$0
0%
1960 1970 1980 1985 1990 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Calendar Year
Source: CMS, Office of the Actuary, National Health Statistics Group.
GDP Share
Billions
$2,000
Table 1.2
National Health Expenditures Per Capita, 1986-2010
National health spending per capita is projected to increase rapidly over the next decade.
$10,000
Actual
Projected
$9,216
$9,000
$8,228
$8,000
$7,000
$6,926
$6,000
$5,757
$5,000
$5,039
$4,000
$4,177
$3,698
$3,000
$3,183
$2,000
$1,000
$2,477
$1,872
$0
1986
1988
1990
1992
1994
1996
1998
2000
Calendar Year
Source: CMS, Office of the Actuary, National Health Statistics Group.
2002
2004
2006
2008
2010
Table 1.13
Health Care Employment by Occupation, 1983-2000
Health care employment growth exceeded that of the general economy.
Percent
Change
1990-02
Radiologic Technicians
32.0% . . . . . . . . . . . . . . . . . . . . . . . . . .
-75.4% . . . . . . .
Health Record Technologists & Technicians
1983
28.7% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14.8% . .
1990
2000
1400
1600
Dental Hygienists
Clinical Laboratory Technologists & Technicians
7.5% . . . . . . . . . . . . . . . . . . . . . . . . .
Physicians' Assistants
39.4% . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Speech Therapists
61.9% . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Physical Therapists
56.5% . . . . . . . . . . . . . . . . . . . . . . . .
48.6% . . . . . . . . . . . . . . . . . . . . . . . . .
Occupational Therapists
Respiratory Therapists
23.8% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
16.9% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
21.6% . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26.6% . . . . . . . . . . . . . . . . . . . . . . . .
-15.2% . . . . . . . . . . . . . . . . . .
Dietitians
Pharm acists
Registered Nurses
Licensed Practial Nurses
Health Diagnosing Practitioners
30.4% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Optom etrists
5.0% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dentists
24.6% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Physicians
95.3% . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medical Scientists
332.2% . . . . . . . . . . . . . . . . . . .
Managers, Medicine & Health
13.8% Total Employment
0
200
400
600
800
1000
1200
Em ploym ent (Thousands)
Source: Dept. of Labor, Bureau of Labor Statistics. Current Population Survey.
1800
2000
2200
Table 1.22
Growth in the Overall Consumer Price Index (CPI) and
Medical-Specific Consumer Price Index (MCPI), 1993-2001
Medical prices have risen faster than overall consumer prices.
7.0%
6.0%
5.0%
4.0%
3.0%
2.0%
1.0%
0.0%
1993
1994
1995
1996
1997
CPI
Source: Dept. of Labor, the Bureau of Labor Statistics.
1998
MCPI
1999
2000
2001
U.S. Healthcare
Forecast Summary
• Health Care Expenditures in 2008
$ 2.2 trillion
16.2% of GDP
Average 1.8% points above GDP 1998-2008
HCFA 1999 Report: National Health Expenditures Projections
U.S. Healthcare
Factors Contributing to Projected
Acceleration in Growth
-
An upturn in private health insurance underwriting cycle
-
Slower growth in managed care enrollment
-
A movement toward less restrictive forms of managed care
-
Continued trend towards increased state and federal
regulation of health plans
HCFA 1999 Report: National Health Expenditures Projections
U.S. Healthcare
Factors Expected to Restrain Growth
-
Implementation of the 1997 balanced budget act
-
A projected increase in the uninsured fraction of the
population
-
The continued (although smaller) impact of managed care
-
The effect of projected excess capacity among health
providers
HCFA 1999 Report: National Health Expenditures Projections
U.S. Healthcare
Objectives
•
Review the Economic Trends of 2003
•
Review the components of Health Care
•
Compare Health Insurance Plans
•
Discuss current issues in health care coverage and
insurance
U.S. Healthcare
Primary Care
Preventive and Treatment measures
Often provided by a physician or nurse practitioner
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Secondary Care
Services available both in community hospitals and
physicians’ offices
Surgeries
Specialists, e.g.. Cardiologists, GI, Derm
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Tertiary Care
- Highly specialized care
- Often at large medical centers
Transplants
Open-heart surgery
Neonatal wards
Chemo- & Radiotherapy
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The Nation's Health Dollar: 2000
Where It Came From
Where It Went
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Components of Health Care
• Consumers
- Insurance
• Providers of Care
- Government
• Institutions that provide care
- Employers
• Support Industries
• Economists / Financing
• Information / Technology
• Higher Education
U.S. Healthcare
Consumers
• US Population
• Minors, Aged, Disabled, Others
• Employed, Not-employed, working poor
Family
Caregivers
Representatives of Consumers
• Activists
• Associations - AARP
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Providers of Care
• Physicians
• Nurses, PAs, Others (SW, Pharm, RDs, PTs)
• Diagnostic and Laboratory Technicians
• Associations / Trade Organizations
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Institutions that Provide Care
• Hospitals, Medical Centers
• Specialty Clinics
Rehab
Drug / Substance Abuse
• Long-term care facilities
• Associations
American Hospital Association
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Government : Federal, State, Local
• Regulatory Role
• Political Process - set regulations, respond to electorate
• Reimbursement
Medicare, Medicaid (States)
• Public Health System
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Insurance Groups
• Blues
• Associations / Trade Organizations
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Support Industries
• Pharmaceutical Companies and Distributors
• Medical Devices
• Medical Equipment
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Employers
Economists
Judiciary; Legal Support
Information / Technology Industry
• WebMD; Drugstore.com
Higher Education
U.S. Healthcare
Components of Health Care
• Consumers
- Insurance
• Providers of Care
- Government
• Institutions that provide care
- Employers
• Support Industries
• Economists / Financing
• Information / Technology
• Higher Education
U.S. Healthcare
• Components of Health Care
SOCIETY
U.S. Healthcare
Objectives
•
Review the Economic Trends of 2003
•
Review the components of Health Care
•
Compare Health Insurance Plans
•
Discuss current issues in health care coverage and
insurance
U.S. Healthcare
Health Insurance Plans
Traditional Care / Fee-for-Service
Health Maintenance Organizations
Preferred Provider Organizations
Medicare
Medicaid
Disability Insurance
Hospital Indemnity Insurance
Long Term Care
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Fee-for-Service
Client may visit any physician, use any hospital
Pay a premium each month
Deductible; after deductible provide a copay
Patient may need to submit bill
Limited services
Preventive Care
Experimental; Home Health Care; Long-term care; PT;
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Health Maintenance Organization
HMOs are organizations that insure groups of individuals
against the costs of medical services and also provide
those medical services
Shouldice 1991
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Health Maintenance Organization
• Pay a premium each month
• Receive ‘complete’ care
• ‘Primary Care Doctor’ you must select
• Some preventive services covered, such as well baby
check ups, immunizations
• Care must be provided by HMO’s practice group
• Cannot self-refer to a specialist
• No claim forms to fill out
• Small copay
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Preferred Provider Organizations
• Combination of a fee-for-service and HMO
• Limits choice of doctors / hospitals
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Preferred Provider Organizations
• Has arrangements with doctors, hospitals, and other
providers of care who have agreed to accept lower fees
from the insurer for their services.
• Copay
• More expensive outside the network
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Medicare
• Health Care Financing Administration (HCFA)
• Largest health insurance program
• 39 million Americans
• Eligibility
65 years of age or older
Some disable persons < 65
End-Stage Renal Disease with dialysis or transplant
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Medicare
• Part A
Hospital Insurance
Funded by SS
• Part B
Supplemental Medical Insurance
Doctor appointments
Other services and supplies
Funded by General Revenues and Premiums
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Medicaid
• Title XIX of the Social Security Act - law in 1965
• Administered by the States
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Medicaid
• Eligibility
* Low income families with children
* Aged, blind, disabled individuals who meet criteria
* Infants born to Medicaid eligible pregnant women
* Children < 6 and pregnant women at < 133% of the
Federal poverty level
* Recipients of adoption assistance and foster care
* Certain Medicare beneficiaries
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Medicaid
• Each of the States:
1. Establishes its own eligibility standards
2. Determines the type, amount, duration, and scope
of services
3. Sets the rate of payment for services; and
4. Administers its own program
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Medicaid and Medicare
Medicare beneficiaries who have low income and
limited resources may receive assistance from State
Medicaid program
http://www.hcfa.gov/Medicaid/meligib.htm
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‘Medigap’
Insurance that covers expenses outside of Medicare
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What does this mean for medical fees?
Consider billing
What the client gets billed depends on the
health care plan.
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What about pre-existing conditions?
“A medical condition diagnosed or treated before
joining a new plan (employment).”
By law (1997) a preexisting condition must be
covered if the person had been insured in the
previous 12 months without a waiting period.
U.S. Healthcare
Objectives
•
Review the Economic Trends of 2003
•
Review the components of Health Care
•
Compare Health Insurance Plans
•
Discuss current issues in health care coverage and
insurance
U.S. Healthcare
Current Issues
Government Reimbursement Rates
State and Federal Government not paying the actual
cost of care for their beneficiaries
* HMOs are dropping Medicare beneficiaries
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Current Issues
Reimbursement for medications
Pharmaceutical spending ’d by 24.8% annually between
1996 and 1998
Americans are:
• Using more prescriptions
• Using prescriptions at a younger age
• Using prescriptions for more conditions
• Substituting newer, more expensive medications
for established products. Blue Shield Press Release 5/10/00
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Current Issues
Consumers report dissatisfaction with HMOs
California survey (6/29/00) found 8 of the largest health
maintenance organizations received ‘low grades’ from physicians
and hospitals for
* quality of care
* patient satisfaction
survey of 85 physician’s groups; 154 hospitals; 25,000 MDs
U.S. Healthcare
Current Issues
Lack of Insurance
Underinsured or Uninsured
1998 = 16.3% of the population
Decreased Number of Health Insurance Companies
Trends in health insurance:
Vermont in 1991 16 companies offering health insurance, in 2000
there are only 3.
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Universal Health Care Coverage
1. Everyone in the US
2. Comprehensive benefits; through primary team and
specialists
3. Elimination of Financial Barriers
4. Financing based on ability to pay
5. Organization and administration through publicly
accountable means
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Universal Health Care Coverage
6. Incentives and safeguards
7. Fair provider payments
8. Ongoing evaluation and planning
9. Disease prevention and health promotion
10. Education and training programs
11. Affirmative action programs in training, promotion, and
employment.
12. Non-discrimination in health services delivery
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Universal Health Care Coverage
13. Education of consumers about their health rights and
responsibilities
14. Attention to the needs of all populations
American Public Health Association; 7/00
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