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Chapter 9

0. Chapter 9. Health Care Systems and Policy. Introduction. In 2000, Americans spent more than $1.2 trillion for health care which represents over 13% of the gross national product This amount exceeds the average amount spent by any other industrialized country. Introduction.

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Chapter 9

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  1. 0 Chapter 9 Health Care Systems and Policy

  2. Introduction • In 2000, Americans spent more than $1.2 trillion for health care which represents over 13% of the gross national product • This amount exceeds the average amount spent by any other industrialized country

  3. Introduction • Public policy is attempting to direct our medical system toward health promotion although Medicaid and Medicare and other major third-party payers offer limited reimbursement for preventive procedures • Many studies show that early detection and intervention, immunization, and behavior change could significantly reduce many of the leading causes of death and disability

  4. An Overview of the Health Care Industry • Two general categories of health insurance in the United States: • Private • Traditional fee-for-service • Group contract • Public • Medicare • Medicaid • State Children’s Health Insurance Program

  5. Private Insurance • Approximately 70.2% of Americans have private insurance • Private insurance can be in the form of traditional fee-for-service insurance or group contract insurance

  6. Private Insurance • Traditional Fee-for-Service Plans • Include a billing system - the provider charges a fee for each service rendered • Critics of this plan claim that they encourage physicians to provide more services than necessary • Proponents prefer the greater flexibility and unrestricted access to physicians, tests, hospitals, and treatments

  7. Private Insurance • Group Contract Insurance • Managed-care systems, - prepaid group practice plans that offer health care services through groups of medical practitioners • HMOs • PPOs • The goal of managed care is improved quality of care with decreased cost • 91% of employees with health insurance were enrolled in managed-care plans in 1999

  8. Company negotiates with specific doctors, hospitals, and clinics These providers must be used by the employee for the reduced fees Employer provides a list of participating providers Employees can choose the physician they want to see instead of being solely restricted to the HMO providers HMOs PPOs

  9. Private Insurance – Group Contract Insurance • In some HMOs, provider receives a capitation payment • Capitation payment – A predetermined fee paid per enrollee per month to the provider

  10. Public Insurance • Medicare and Medicaid • State Children’s Health Insurance Program • CHIP

  11. The Medicare Program • Medicare is the largest health care insurer in the U.S. • It is designed to assist: • People 65 and older • People of any age with end-stage renal disease • People eligible for Social Security disability payment programs for more than 2 years • Qualified railroad retirement beneficiaries and merchant seamen

  12. The Medicare Program • Medicare consists of two separate parts: • Hospital insurance (Part A) • Medical insurance (Part B)

  13. The Medicare Program • Medicare Part A • Provides hospital insurance benefits that include up to 90 days of inpatient care annually with a 20 percent coinsurance fee • Hospital inpatient charges are reimbursed according to prospective payment system known as diagnosis related groups (DRGs)

  14. The Medicare Program • Medicare Part B • An optional insurance program financed through premiums paid by enrollees and contributions from federal funds • Enrolled Medicare Medical Nutrition Therapy (MNT) providers are able to bill Medicare for MNT services provided to beneficiaries with type 1, type 2, and gestational diabetes, nondialysis kidney disease, and post-kidney transplants

  15. The Medicaid Program • Medicaid is a joint state and federal program that provides assistance with medical care for: • Eligible, low-income persons • Certain low-income pregnant women and children • The aged, blind, and people with disabilities • Members of families with dependent children in which one parent is absent, incapacitated, or unemployed

  16. The Medicaid Program • The individual states define eligibility, benefits, and payment schedules • Typically, one must meet three criteria • Income • Categorical • Resource

  17. The Medicaid Program • Medicaid covers a variety of services and settings, including inpatient and outpatient hospital services, physicians’ services, skilled nursing home and home health services, and laboratory and x-ray tests • To date, 36 state Medicaid programs cover certain forms of nutrition services provided by dietitians

  18. The State Children’s Health Insurance Program • The State Children’s Health Insurance Program (SCHIP) is the largest single expansion of health insurance coverage for children in more than 30 years • States have flexibility in targeting eligible uninsured children • Many of the children served come from working families with incomes too high to qualify for Medicaid but too low to afford private health insurance

  19. SCHIP Enrollment,1999-2003

  20. The Uninsured • The uninsured include the working poor and those who work for small businesses • The employed uninsured number 15 million

  21. The Uninsured • The non-working uninsured number 9 million and include: • The homeless • Some deinstitutionalized mentally ill patients • Low-income people who do not qualify for Medicaid

  22. % of U.S. Persons without Health Care Coverage, 2003

  23. Demographic Trends and Health Care • By the year 2030, the baby boom will become a senior boom with 21 percent of the population over 65 years of age • Racial and geographical factors in the population are also important to the shape of the future

  24. The Need for Health Care Reform • Health care reform refers to the efforts undertaken to ensure that everyone in the U.S. has access to quality health care at an affordable price

  25. The Need for Health Care Reform • Some of the challenges of health care reform include: • Making health care accessible to everyone • Containing costs • Providing nursing home care to those who need it • Ensuring that Medicare and Medicaid can serve all who are eligible

  26. The Need for Health Care Reform • Cost, access, and quality are interrelated and manipulating one has an astounding impact on the others • Health care policy makers are studying alternative models of delivery and financing in hopes of applying other nations’ successes to the U.S.

  27. The High Cost of Health Care • Health care inflation is well established and the level of health care activity is expected to grow as a result of various factors including: • An aging population • Increased demand • Continuing advances in medicine

  28. National Health Expenditures (Billions of Dollars)

  29. The High Cost of Health Care • Major contributors to health care expenditures in the U.S. are: • The administrative cost of the insurance process itself • Professional liability costs

  30. The Nation’s Health Dollar, 2002

  31. The High Cost of Health Care • Efforts at Cost Containment • Efforts to curb soaring health care costs cover a broad spectrum... • from slowing hospital construction • to reducing length of hospital stays, and • and increasing co-payments and deductibles for insured employees and Medicare recipients

  32. The High Cost of Health Care - Cost Containment • One example of cost containment is the prospective payment system (PPS) that the federal government implemented • The purpose of the PPS was to change the behavior of health care providers by changing incentives under which care is provided and reimbursed

  33. The High Cost of Health Care - Cost Containment • PPS (continued) • Prospective payment means knowing the amount of payment in advance • PPS uses diagnosis related groups (DRGs) as a basis for reimbursement • Patients are classified according to the principal diagnosis, secondary diagnosis, sex, age, and surgical procedures

  34. The High Cost of Health Care - Cost Containment • PPS (continued) • There are 23 categories and a total of 490 DRGs • One consequence of PPS has been an increased focus on outpatient services

  35. The High Cost of Health Care • Equity and Access as Issues in Health Care • Public opinion polls in the U.S. reveal that most people believe all citizens are entitled to access to health care... • but debate continues about the acceptable level of health care and what benefits should be included

  36. The High Cost of Health Care – Equity and Access • Racial and Ethnic Disparities in Health • A recent report released by DHHS shows significant improvements in the health of racial and ethnic minorities but also indicates that important disparities in health persist

  37. Health Care Reform in the United States • Almost all industrialized countries except the U.S. have national health care programs • In these systems, coverage is generally universal and uniform and costs are paid entirely from tax revenues or by some combination of individual and employer premiums and government subsidization

  38. Health Care Reform in the United States • Health care reform in the U.S. raises a formidable list of issues including: • Overall cost containment • Universal access • Emphasis on prevention • Reduction in administrative superstructure and costs

  39. Health Care Reform in the United States • While the government remains undecided on what kind of health care system is needed or how to pay for it, health care reform is evolving at an accelerating rate without legislation

  40. Nutrition as a Component of Health Care Reform • Many believe that nutrition services are the cornerstone of cost-effective prevention and are essential to halting the spiraling cost of health care

  41. Nutrition as a Component of Health Care Reform • The American Dietetic Association (ADA) has urged that nutrition services be included in any health care reform legislation • Registered dietitians also need to be recognized as the nutrition experts of the health care team

  42. Nutrition as a Component of Health Care Reform • Cost-Effectiveness of Nutrition Services • ADA encourages all of its practitioners to document the cost-effectiveness of nutrition services • Cost-effectiveness studies compare the costs of providing health care against a desirable change in patient health outcomes

  43. Nutrition as a Component of Health Care Reform • Cost-Effectiveness (continued) • Effective nutrition therapy can produce economic benefits as a result of altered food habits and risk factors • Practice guidelines or protocols that clearly specify appropriate care and acceptable limits of care for each disease state or condition are important to enhance the quality, efficiency, and effectiveness of the health care system

  44. Nutrition as a Component of Health Care Reform • Care delivered according to a protocol has been linked with positive outcomes for the client • Examples of outcomes include: • Measure of control (serum lipid profiles) • Quality of life • Dietary intake • Patient satisfaction

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