HSA NOTES (1)

1. Reduced number of uninsured Americans 2. Medicaid became popular 3. People with preexisting conditions helped 4. Regulatory mandates- cost spiraling 5. Competition kept premiums high 6. Negative effect on employer-based insurance 7. Better preventive care, affordability, care for chronic conditions NEW CHALLENGES - Court cases decided in favor of ACA. - Most Americans approve of ACA but want changes. CHAPTER 4 – HEALTH SERVICE PROFESSIONALS Behavior and lifestyle. Lack of exercise, poor nutrition, tobacco, alcohol. - Occupation with the most new jobs in the hospital= registered nurses - Highest salary= Medical and Health Service Manager - Occupation with the most new jobs in nursing and residential care facilities= CNA - Why? Because they directly help the elderly - Highest salary=nurses - Occupation with the most new jobs in the outpatient, lab, and ambulatory facilities= registered nurses-highest salary, paramedics SHIFT FROM ACUTE TO CHRONIC ILLNESS - Better coordination of care by doctors. - Extending healthcare to new settings - Mental health - Improving relationships with community organizations - Using social media for health messages

- Precision- of treatments for individual patients RURAL STATES HAVE SHORTAGE OF DOCTORS - Geographic maldistribution - Physicians per 100k population. - They get paid more in rural areas like Alaska. MORE DOCTORS ARE BECOMING SPECIALISTS - Why? Specialists get paid more, and longer residency. - Nurses/PAs are filling in the gap between specialists and primary care doctors. WHY ARE HEALTHCARE COSTS GOING UP? - Americans want the best resources and technology for health. - Specialists/hospitals want the best tech to compete with each other. - Growing elderly on life support. WHAT IS MEDICAL TECHNOLOGY - Pacemakers - Telemedicine - CAT scans - Google glasses- used during surgery HEALTHCARE SPENDING AS % GDP - The US spends more on healthcare than any other country NEXT STEPS IN HEALTHCARE - Instead of a fee for each service to be result-based. - Treat the entire person not just the symptoms so that they don’t come back. - Treat populations of people rather than one person at a time - Having a primary care physician who continuously follows your treatment. - Retrospective -predictive information IT APPLICATIONS

- Interoperability- information from one place to another. No duplicates, lower costs. HIPAA DISCUSSION - Law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge . - Right to an electronic copy of information. Or an online patient portal that gives access to this information. - If you paid out of pocket, you have the right to tell the doctor not to share this information with your health plan. - Right to tell hospitals to not send fundraising letters for marketing and sales. - Right to file a complaint if your info was used wrong. - Create a security plan for the office. Start with risk analysis. Develop administrative safeguards, deciding who gets access to confidential info. Physical safety-security locks, alarms, positioning heavy machine away from patients. Technical safeguard- keeping viruses away from computers, encrypting health records on computer hard drives to keep them confidential. - Stark law- prohibits physicians from referring patients to receive "designated health services" payable by Medicare or Medicaid from entities with which the physician or an immediate family member has a financial relationship PRICE OF PHARMACEUTICAL PRODUCTS IN THE US - It is continuously increasing. - Bavencio- drug that costs 156k a year, per patient - Who approves drugs? Food and drug administration. - Cost of clinical trials- reason for high cost. - 242 people for this drug trial. Few died but it was still approved because it can atleast increase chances of curing the disease. - Sarepta- 300k drug. Only 12 boys in the study. Can provide financial assistance. Example of social justice. - Tecentriq- bladder cancer. Failed phase 3 trial. Loss for company. - Insulin- price gone up three times with no change in effectiveness. - Opioid addiction. Number of deaths increasing. - Ezvio- raised their price over 4000 from 699 as opioid overdose increased.

- Moral hazard weapons/cost sharing 1. Copayments 2. Deductibles 3. Coinsurance NOT COVERED UNDER COMPREHENSIVE INSURANCE - Dental - Eye exams COST CONTROL - Restrict insurance- what/not covered - Restrict reimbursements to providers- doctors not getting paid enough for taking care of medicare, Medicaid patients. - Less specialists - Direct control over utilization-supply side rationing Why to control cost- balancing act to keep the system going. PIE CHART - Issuing agency that assumes risk- insured/underwriter - Underwriting- systematic technique of evaluating risks. - Insurance- 52.8% private, 32.5% public(Medicaid, medicare, chip), uninsured-driving up costs as they go to hospitals. INSURANCE - Protects you against risk - Risk- possibility of substantial financial loss - Insurance companies collect premiums of a large number of people and because the probability of a risk occurring is small, these companies make a huge profit. INSURANCE FUNCTION - Three methods are used to determine premiums:

- Medigap- need to have medicare for this. Doesnt cover long term care, vision, dental or private nursing. PRIVATE COVERAGE AND COST UNDER AFFORDABLE CARE ACT Six main provisions: 1. Enroll young adults till age 26 under parents plans 2. Illegal to charge more 3. Medical loss ratio GENERIC REIMBURSEMENT METHODS - Fee fore service (FFS) - Retrospective - Looking back - Prospective- looking in the future - Capitation CHAPTER 7- OUTPATIENT/ AMBULATORY CARE SCOPE OF OUTPATIENT CARE - Growing since 80s. Patients favor. - Financial incentives to reimburse outpatient care. - Less invasive - Less traumatic - Shorter anesthetics/ fast recovery. Value-Based Care: A shift from fee-for-service to value-based care models, where healthcare providers are incentivized to focus on patient outcomes and quality of care rather than the volume of services provided. OUTPATIENT AND PRIMARY CARE - Hospitals- best outpatient care. Better equipment, more equipment, more diagnostics. They help underserved populations. They bring in different doctors for different communities. Helpful for people with no insurance. More comprehensive. Has had a lot of growth. - Tertiary care- long term care. Burn, open heart surgery etc. - Primary health care- universally acceptable, at an affordable cost, designed to be at the first level of content. Point of entry, gatekeeper, coordination of care. Delivery of care- includes primary and secondary care, example-consultation with

- WHO OPENED 1ST PROPRIETARY HOSP- physicians CHAPTER 8- INPATIENT FACILITIES AND SERVICES - Inpatient- overnight stay at hospital - Gvt Hospital- ● atleast 6 beds ● organized staff ● governing body (responsible for conduct of hospital) ● Ceo ● Registered pharmacy ● Food service - Florence nightingale- transformed nursing. Nursing uniform like military. - Marie Curie- cancer, radiation. - Dame Cicely Saunders- hospice. Helps patient die with dignity. - 1946 (After war) - Hill Burton Act - gave federal money to communities to build non profit hospitals. Every town, city. ● One condition- charity care. ● Made it mandatory for private insurers to cover hospital services. ● Relieve shortage of hospitals. ● Curtail utilization of hospital beds. ● Have federal control over community hospitals. ● A built bed is a filled bed. - 1965-80- Medicare medicaid - 1980- downsizing phase. Managed care changed payment structures. Nixon was president at this time. - States that did not accept medicare funding are not doing well. - Types of hospitals 1. non profit=51.1% 2. state and local gvt=17.9% 3. private for profit=18.7% 4. psychiatric(non-federal)=7.2% 5. federal=3.8% 6. long term non federal=1.3%.

GATEKEEPING - Controlling factor - Providers have to deal with many problems. - MCOs negotiate with labs, they want patients to use only a specific lab. - MCOs didnt provide necessary surgeries that patients needed, so people died. - Primary care delivery, secondary care referral. ● Diagnostic test ● Specialist consultation ● Hospital admission ● Mental health referral ● Management CASE MANAGEMENT - 10% patients with chronic conditions represent 70% healthcare spendings. - Once patient is in hospital, costs can go to 50% of all medical care provided. ● Monitoring ● Coordination ● Support ● Information PPO (preferred provider orgs) - Instead of capitations, ppos make discounted fee. - Most popular MCOs - 25-35% off regular fee. Desensitize- unaware REVIEWS - utilization - Why do you need a service - If its cost efficient - Prospective- make decision to authorize, if second opinion is needed. - Concurrent- when patient is already in hospital. - When to release patient, length of stay, drugs. - Retrospective- looking at over/under utilization, billing accuracy. STAFF MODEL

- Physicians receive salary- upfront cost. - MCOs have control over this. - One stop shop for patients. - Disadvantage- patients paying providers salary upfront. - Disadvantage for insuree- limited choice for which physician they can see. - Group practice- MCO makes a multi specialist group, and pay capitation per head. - Disadvantage- if you lose contract with one group, hard to get another. NETWORK MODEL - Used in metropolitan areas. - Different groups and financial responsibility is spread out. Harder for MCO to control. - Utilization gets diluted. IMPACT ON COST, ACCESS, QUALITY - Vertical/horizontal integration. - Losing rural hospitals in america. PROFESSIONAL LIABILITY INSURANCE - Medical malpractice - Professional liability - Professional negligence - Medical negligence - Nature of liability insurance- protect licensed healthcare prof from liability associated with wrong practices resulting in body injuries, medical expenses, property damage, costs of defending lawsuits. INSURANCE TYPES - Occurrence policy- if you get a lawsuit for a prior job, you still get all the benefits. - Claims made policies- Less expensive. if you get a lawsuit for a prior job, you will not get benefits. Therefore you need tail coverage- covers claims after expiration of claims- made. - Occurrence monetary limit- for individual event. - Aggregate- culmination of individual events. - First layer of insurance - basic coverage. Taken first in case of lawsuit. - Excess- above basic, extra money.

INDUSTRY RATES - Insurance is expensive due to industry rates. We need to have rates to generate funds to cover losses during the period of time. - Administration costs, running a company, unknown number of losses. - Insurance coverage depends on specialty and geographical location. RESERVES AND REINSURANCE - reserves - Liabilities based on that are based on estimates of future amounts needed to satisfy a claim. What we have in a reserve to pay future costs. - Reinsurance- insurance again from other insurers for big losses. MEDICAL MALPRACTICE CRISIS - In the 70s and 80s, increase in prof liabilities. - Physicians were tired of paying high prices, so they decided to come together and make physician owned practices. - Example- the doctors company. PROFESSIONAL LIABILITY VIDEO PART 2 RESPONSES TO THE CRISIS - Benchmark for evaluating reform- to ensure positive change in healthcare delivery. ● Do reforms improve the operation of the tort system for compensating victims. ● Do reforms create incentives for the reduction of medical errors, resulting in injury to patients. ● Do reforms encourage insurers to make liability insurance more available and affordable. IMPROVING INSURANCE AVAILABILITY Many new insurance were made after the crisis: - Joint underwriting associations - Reinsurance exchanges - Hospital self insurance - Provider owned insurance companies - Insurers wrote policies based on claims made rather than occurrence made.

TORT REFORM - Tort- civil wrong. One individual suing another. - Common tort reforms: ● Reducing filing of claims - Reduced statute of limitations- the amount of time after when a wrong occurs, that you can bring a lawsuit. In a medical malpractice, you have 2 years to sue. - Controlling legal fee- reduction in the amount of money that a claim’s attorney can get from a lawsuit. ● Limiting the plaintiff’s(victim) award - Caps on noneconomic damages(not quantifiable-pain in a suffering). - Collateral source rule- prevents jury from learning of sources of compensation. - Periodic payments- converts award for future losses from lump sum to periodic payments. ● Altering the plaintiff’s burden of proof- not having definite proof but holding the company accountable for what happened. But for medical malpractice there needs to be expert testimony. Need to have testimony from same medical specialty. ● Changing the judicial role- pre-trial screening. Instead of the court, have a medical panel who know the merits of a case before presenting it to the law. ● Arbitration- replaces a jury trial. JUDICIAL RESPONSE - Challenges based on denial of the equal protection clause or due process clause of the 14th amendment. - EPC- equal protection of laws. medical malpractice claimants argue that they are being discriminated against in class. - Courts may discriminate as long as there is a rational relationship between classification and state objective. (rational basis review) - Due process clause- Constitutions ensures that the state action will not deprive a citizen of life, liberty or property without due process of law. (right to sue=property) - Final reform- Adding medical malpractice guidelines to the court room practice. - AMA has added this. RATIONALES FOR AN ALTERNATIVE SYSTEM - Tort system- does not compensate injured patients. Less than 2% claim. - Inaccurate deterrence signals. They compensate very few people very little amount.

80% got monetary compensation. They’re compensating just because they don’t want to go to trial. - Administrative costs of malpractice. - Impairment of patient access by malpractice costs. REFORMS - ADR (alternative dispute resolution: ● Mediation- voluntary compensation. Both parties agree. ● Arbitration- requires independent third party. - No fault system- insurer will pay regardless of the fault of the insuree. - Social insurance- removed all damage claims from the tort system. - Impact on cost containment ● Primary responsibility for cost falls on private sector. ● In other nations, gvt controls costs by limiting services and payments to providers. ● MCO in 1980s- backlash. ● Managed care controlled costs during 90s. ● There was backlash again- freedom. ● Recent moderation of premium increases= increased cost sharing. MANAGED CARE PAYMENT MECHANISMS - Capitation - provider is paid fixed monthly sum per enrollee (PMPM-per member per month). - What shift? - Discounted fees- modified of fee-for-service. - Discounts off regular fee 25%-35% PROFESSIONAL LIABILITY INSURANCE- test 2 - Occurrence based policies vs claims made policies. - Occurrence vs aggregate monetary limits. - Tort- wrongful a ct or an infringement of a right leading to civil legal liability . explain 4 common tort reforms related to professional liability reforms. Medicare enrollees with functional limitations - Page 401 - ADLs

- Vs - Instrumental ADLs - 3+ ADL limitations- nursing homes. SNF- skilled nursing facility- short term with medical specialists with many forms of rehab. NF- nursing facility- long term care What about LTC facilities admitting these patients? ● Monopolies are bad for the economy. Page 409. PERCENTAGE OF WORKER ENROLLMENT IN HEALTH PLANS- Companies are promoting high deductible plans. SERVICE STRATEGIES - Horizontal - major expenditure - Vertical - sub categories involved Ch10,11 not on test. Short term, pt at home- medicaid Long term, hospice- medicare CHAPTER 10- LONG TERM CARE MAJOR LTC ISSUES - medicare/pvt insurance provide minimal coverage for ltc. - Medicaid eventually pays for it. - To qualify for medicaid, must be broke. Who have no more than $2000 in assets. - Medicaid’s largest expense- ltc. CHAPTER 11- POPULATION HEALTH - CHIP- president Clinton - Ryan white- new morbidity - depression

CHAPTER 12- COST, ACCESS, EQUALITY - Three cornerstones of healthcare delivery- cost, access equality. - 17.4- GDP COST OF HEALTHCARE - Comparing our healthcare spending to other countries. - Seeing if the cost of private health insurance is going up. - Checking how much the government spends on healthcare for people who get benefits. - The idea is to make sure we're not spending too much on healthcare and to find ways to manage the costs. RISING COSTS IN HEALTHCARE DUE TO: 1. Third-Party Payment: This means that when someone else (like insurance) pays for our healthcare, we might not be as careful with the costs, which can make healthcare more expensive. 2. Imperfect Market: In healthcare, it's not always easy to compare prices and quality like we can with other things we buy. This lack of clear information can lead to higher costs. 3. Growth of Technology: New and advanced medical technology is expensive to develop and use, which can drive up healthcare costs. 4. Increase in the Elderly Population: As more people get older and need more healthcare, it can strain resources and lead to higher costs. 5. Medical Model of Health Care Delivery: The way healthcare is organized and delivered, which often focuses on treating illnesses instead of preventing them, can also contribute to higher costs. 6. Multiple Insurers and Administrative Costs: When there are many different insurance companies and a lot of paperwork, it can make healthcare more expensive because of all the administrative work. 7. Defensive Medicine: Sometimes, doctors order extra tests or treatments to avoid legal problems, which can increase costs. 8. Fraud and Abuse: Some people or businesses cheat the healthcare system, like by

billing for things they didn't do. This fraud makes healthcare more expensive. 9. Practice Variations: Doctors in different places might do things differently, and some places might have higher costs for the same care. This can lead to cost differences between areas. WAYS TO CONTROL COSTS OF HC (REGULATORY APPROACH) 1. Health Planning: This means making plans to manage healthcare in the U.S. and trying out new ideas. It includes something called "Certificate-of-Need" rules, which require permission before building new healthcare facilities to avoid overspending. 2. Price Controls: This is about setting rules to keep healthcare prices from getting too high. It's like making sure things don't cost too much. 3. Peer Review: This is when experts in the medical field check and review the work of other doctors to ensure it's good quality and cost-effective. It's like a quality check for healthcare. COMPETITIVE APPROACH 1. Demand-side incentives: Encouraging patients to choose more affordable options. 2. Supply-side regulation: Setting rules for healthcare providers to keep prices in check. 3. Payer-driven price competition: Insurance companies negotiate lower prices with healthcare providers. 4. Utilization controls: Managing how much healthcare services are used to prevent unnecessary costs. HEALTHCARE REFORM APPROACH Health reform included steps to control costs in healthcare. They did this by reducing how much Medicare pays to healthcare providers and adding new taxes. These changes helped slow down the growth in healthcare spending. Medicare, a health program for seniors, is expected to spend $1 trillion less by 2020 because of these changes. The goal is to make healthcare more affordable and efficient. ACCESS TO CARE Access to healthcare is really important because it affects our health and how we get medical care. It's like a way to check if the healthcare system is working well.

There are five things that make up access to healthcare: 1. Availability: This means having medical care nearby and ready for people when they need it. 2. Accessibility: It's about making sure that people can easily access medical care, like having hospitals and clinics in the right places. 3. Accommodation: This is about making healthcare comfortable and convenient for patients. 4. Affordability: Healthcare should be something people can pay for without it being too expensive. 5. Acceptability: Healthcare should respect people's beliefs, cultures, and preferences so they feel comfortable getting care. When these five things are working well, it means people can get the right care when they need it, and it's fair for everyone. Four Main Types of Access 1. Potential access 2. Realized access 3. Equitable or inequitable access 4. Effective and efficient access MEASUREMENT AND CURRENT STATUS OF ACCESS How we measure and understand people's ability to get healthcare. We measure it in three ways: ● for individual people ● for the health insurance they have ● for the places that provide healthcare. We also want to know how easy or difficult it is for people to get the healthcare they need right now. This helps us figure out if there are any problems with access to healthcare. AFFORDABLE CARE ACT AND ACCESS TO CARE

Affordable Care Act (also known as Obamacare) has helped more people get health insurance and access to medical care. This means fewer people have trouble paying their medical bills or facing financial barriers to getting healthcare. However, there are still some gaps in who can access care and how affordable it is for everyone. The law has also made it easier for people to get preventive services without having to pay extra money for them. QUALITY OF CARE The quality can vary from really bad to really good. It's about the care you get from the healthcare system. We can look at quality from the point of view of individual people and also the whole community. The most important thing is to make sure people get the good health results they want from healthcare. DIMENSIONS OF QUALITY "micro view" of quality, we're looking at the quality of healthcare services when they're given directly to a patient. This includes things like how well the treatment works (clinical aspects), how the healthcare providers interact with the patient (interpersonal aspects), and how the treatment affects the patient's overall well-being and happiness (quality of life). On the other hand, the "macro view" looks at quality from a broader perspective. It's about how good healthcare is for the entire population, not just one person. So, it considers things like the overall health of a community or country and how well healthcare services are working on a large scale. QUALITY ASSESSMENT AND ASSURANCE quality assurance in healthcare is like making sure things are done the right way to provide good care. It's based on a system called total quality management. One important model for this is the Donabedian model. To improve quality, healthcare uses things like guidelines for how to treat patients, making sure things are cost-effective, following plans for patient care, and managing risks to keep patients safe. These processes help make sure healthcare is of high quality. Critical thinking test 3: - Are pharma companies simply turning a blind eye to excessive profit making at the expense of society. - What are the goals for learning more about policy

- Default concepts article intro, conclusion - page 2-6, 36-38 - Antitrust concepts- protect competition article intro, conclusion. Pg 2-4, pg 34. - “Pick the best response that does not preserve..” - Lowering drug prices in medicare part D. - Timetable for medicare prescription drug price negotiations- takes too long/too much money. - $50 billion/8.2million medicare beneficiaries. - New law- inflation act - Medicare, a- ambulation, b-physician, c-miscellaneous, d-drugs. - Caregiver exemption - Medicaid dark secret- the program that provides hc to millions low income americans is not free. It’s a loan. And the gvt expects to be repaid. - If any real property is not homestead (primary residence) protected it needs to be sold to pay medicaid. - Medicaid lookback period. Begins the day someone applied for medicaid and goes back 5 years in all states but cali. Each state has a penalty divisor per month. - Medicaid child caregiver exemption. - Capitol expenditure- large expenditure. ● Check weekly reports.