HP353 EXAM2

HP353 EXAM2 Review small group discussion topics from class on 10/20. Chapter 8-9 Why does U.S. health care cost so much? 1. Factors related to healthcare system  Lose governmental regulation  Overtreatment  Emergency department overuse  Lack of coordination/standardization, etc. 2. Factors related to disease and society  Increase in chronic disease  End of life care costs  Unhealthy behaviors  Poor health literacy Health expenditures as a percent of GDP - 17% (in 2013) - It matters because it takes money from other fields people can benefit from - Health expenditure increased from 9.6% (1980) to 17.6% (2009). BUT little change in % expenditure in the past 5 years because of 1. poor economic growth. 2. High out-of-pocket costs are discouraging 3. ACA power: payment for Medicare has been reduced Health costs and outcomes model - Provides framework for decision making - Enables examination healthcare costs and benefits from improved health outcomes - Interests of a population not an individual - Y axis = health outcomes = aspects of health status directly under the influence of health care, not the broader economic and social factors - - A to C: improve healthcare quality with same healthcare cost - This model focuses on the overall health of a population, not individuals

Cost control: Painless/painful - C ost = P rice x Q uantity Cost increases as price increases, quality remains unchanged. Painless cost control Painful cost control 1. Decrease the administrative cost 2. Less cost of technology 3. Cutting price of pharmaceuticals 4. Decrease reimbursement to providers 1. It depends on a person’s view Overall beneficial health outcome may place pain on some individuals 2. Sacrifice quantities of medically beneficial services 3. Rationing Why control price? 1. More money left in our pocket 2. Price goes up in healthcare, premium/insurance fee goes up Price inflation has been shown to be a major contributor to increased health care costs Why control quantity? 1. High quantity does not correlate to high quality 2. Higher costs exist in areas with more specialists and hospital beds - How? 1. Stop doing things of no proven clinical benefit 2. Reduce inappropriate care 3. Decrease administrative waste 4. Unnecessary innovation 5. Prevention costs > treatment 6. COST EFFECTIVENESS Decrease administrative cost controls both price and quantity. Cost containment : measures are controversial and difficult to implement - Ideal: improve health outcomes in a population through “painless” routes of making more efficient use of existing resources Strategies for cost control: Financing and Reimbursement controls Financial transaction includes: 1. Financing: flow of money from individuals and employers to health plans 2. Reimbursement: flow of money out of health plans to provides Financial controls 1. Regulation of taxes controls public expenditure for health care (e.g. Medicare A)  Time consuming 2. Market forces (competitive premium price): effective  But, U.S. is not successful  Not knowing how much actually cost  Employers can choose a less expensive insurance to cover  A more expensive plan may not be the best choice Reimbursement controls – MIXED CONTROLS (both price and quantity) 1. Price controls (some progress but limited)  Regulation & Competitive

2. continuous approach: reduce waste, unnecessary treatment 3. clinical practice guidelines 4. quality report cards 5. pay for reporting Healthcare Effectiveness Data and Information Set (HEDIS) - indicators: e.g. immunization, mammograms - National Committee for Quality Assurance (NCQA) used to evaluate the quality of health plans operating in the U.S. - goal is to compare performance, improve care, and overcome financial incentives that restrict appropriate care Methods to achieve malpractice reform Tort 侵权行为 reform it limits the amount of compensation that plaintiffs may recover and place caps on attorney’s fees. Unfair to worse injuries. Alternative dispute resolution Substituting mediation 调解 and arbitration 仲裁 for jury trials. More compensation to injured parties. No-fault reform Not implement in the U.S. Providing compensation to patients due to negligence Enterprise liability Institutions take the responsibilities Pay for Performance- medical initiatives Components of high-quality care 1. access to care 2. adequate scientific knowledge 3. competent health care providers 4. separation of financial and clinical decisions 5. organizations of health care institutions to maximize quality Chapter 12- long term care Medicare- no maintenance coverage in any setting but short term (up to 100 days per episode of illness) for skilled care in a skilled nursing facility. Medicaid is the only insurance that covers 24-hour maintenance long term care in a nursing home. (other than individual private long term care policy) Hospital care: acute + chronic conditions Rehabilitation Facility: patient must be able to tolerate and benefit from a min. of 3 hrs therapy/day Skilled Nursing Facilities: Medicare pays for short term skilled care (100days) 1. skilled nursing level 2. maintenance/ custodial level = unskilled care Nursing Home: custodial only (not a benefit under Medicare) - quality varies widely - elder residents Hospice 1. covered under Medicare only if the patient is terminally ill (<6 months) 2. GAPS: intermittent care

Home care: - Only short term - Medicare reimbursement is “episode of illness” (<60days) - Mismatch (high-tech needs and inadequate skills) Medicare covers when 1. Intermittent skilled nursing is required 2. Patient is homebound (takes effort to leave) 3. Great expectations from the treatment Mostly informal caregivers at home setting take care of patients in need of long-term care + community-based + nursing home (institutional settings) Budget Reconciliation Act - It set standards for nursing home quality and mandated surveys to enforce these standards - It includes (reforms): Who pays for long term care (LTC) - Medicare does not cover for custodial care - Medicare covers for nursing home but not 24hr custodial home care - Private long-term care insurance How can long term care be improved? = Overall proposals for LTC 1. Develop social insurance 2. Shift to community based care 3. Train and support family members as caregivers 4. Expand comprehensive acute and long-term care organizations modeled on On Lok Social insurance - A system of compulsory/guaranteed contribution to provide gov’t assistance in sickness, unemployment, etc. - E.g the Pepper commission - Challenge: funding ADLS: activities of daily living - Feeding, dressing, bathing, getting to/from toilet, getting in/out of a bed IADLS: instrumental activities of daily living - Doing housework, preparing meals, using transportation, managing finance, taking meds, On Lok program - A community-based care service model - Financed by capitation (blends Medicare and Medicaid) - Minimize hospitalization; >55yrs old  HOW? -Legislation change ACA reforms for LTC (supreme court) 1. Community first choice option: support in-home programs 2. Balancing incentive program: increase funds in states for home/community service 3. Husband/wife saves more for qualifying Medicaid ACA strengths and expands the MFP program allowing more states to apply

Refusal of treatment - For those possess DMC & surrogate decision-makers have the right to make such decisions Meaningful language Withholding treatment, withdrawing treatment Time limited trials : giving the patients control in having the option to stop a treatment Egalitarian vs consequentialist approaches to allocating resources Egalitarian consequentialist All persons in need are treated as equals 1. The principle of saving no one- with limited resources, decisions are made not to treat anyone 2. The principle of medical neediness- everyone with a medical need is considered 3. The principle of general neediness- everyone with a general need is considered 4. The principle of queuing- first come first served 5. The principle of random selection-everyone has a chance to be treated Outcome-based decision making 1. The principle of medical success- deciding who will have the best chance of a good outcome 2. The principle of immediate usefulness- deciding who can benefit based on what they can contribute—e .g soldiers that can go back into combat 3. The principle of conservation- basing the decision on whom will save the most resources 4. The principle of parental role-who is best able to watch over others, e.g. parent over children 5. The principle of general social value- who has the most to contribute to society Rationing by medical effectiveness Distributive justice 1. Equal share 2. Need 3. Effort 4. Contribution 5. Merit 6. free market change Chapter 15 (T/F) True- ACA = Obamacare 4 main components of reform under the ACA 1. Individual mandate: all Americans have to have insurance 2. employer mandate, 3. expansion of Medicaid eligibility (decreases uninsured population ) 4. Insurance market regulations Financing reform Individual penalty- taxing people without coverage Increase Medicare tax on wages and unearned income, excise tax on insurers that provide costly health plans, pharm industry fees (may cut-off production/research tho ), insurance co. fees, medical device fees Employer “ pay or play ” requirements- tax benefits - >50 ppl large firm & penalty excludes first 30 ppl; 95% total employee covered

Health Insurance exchanges - for ppl to shop individual insurance plan - bronze (lowest premium but highest benefits); platinum vise versa Small business tax credits - <25 ppl; <$50,000; 35% tax credits = lower taxes Key ACA coverage measures 1. up to 26 yrs old for dependent coverage 2. high-risk health insurance pool for pre-existing conditions 3. benefits for children (denied & pre-existing conditions) 4. reduction of the coverage gap for prescription meds (Medicare D) 5. expansion of Medicare 6. individual mandate 7. subsidizing uninsured people 8. employer mandate (>50 employees) *state children health insurance program (SCHIP) : parents do not qualify for Medicaid and cannot afford for their children’s insurance either Efforts that will contain costs - prevention care & community health - eliminate cost-sharing - more taxes Efforts to improve prevention efforts - women 4 ways people can get insurance under the individual mandate of the ACA - Medicare - Medicaid - Employment-based - Marketplace