Objectives Review the Economic Trends of 2003 Review the components of Health Care

2. 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

3. 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

4. National health spending growth is projected to significantly increase as ashare of GDP over the next decade. Projected Actual Source: CMS, Office of the Actuary, National Health Statistics Group.

5. Table 1.2 National Health Expenditures Per Capita, 1986-2010 National health spending per capita is projected to increase rapidly over the next decade. Actual Projected Calendar Year Source: CMS, Office of the Actuary, National Health Statistics Group.

6. Table 1.13 Health Care Employment by Occupation, 1983-2000 Health care employment growth exceeded that of the general economy. Percent Change 1990-02 32.0% -75.4% 28.7% 14.8% 7.5% 39.4% 61.9% 56.5% 48.6% 23.8% 16.9% 21.6% 26.6% -15.2% 30.4% 5.0% 24.6% 95.3% 332.2% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.8% Total Employment Source: Dept. of Labor, Bureau of Labor Statistics. Current Population Survey.

7. 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. Source: Dept. of Labor, the Bureau of Labor Statistics.

8. 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

9. 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

10. 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

11. 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

12. Primary Care • Preventive and Treatment measures • Often provided by a physician or nurse practitioner

13. Secondary Care • Services available both in community hospitals and physicians’ offices • Surgeries • Specialists, e.g.. Cardiologists, GI, Derm

14. Tertiary Care • Highly specialized care • Often at large medical centers • Transplants • Open-heart surgery • Neonatal wards • Chemo- & Radiotherapy

15. The Nation's Health Dollar: 2000 Where It Came From • Where It Went

16. Components of Health Care • Consumers - Insurance • Providers of Care - Government • Institutions that provide care - Employers • Support Industries • Economists / Financing • Information / Technology • Higher Education

17. Consumers • US Population • Minors, Aged, Disabled, Others • Employed, Not-employed, working poor • Family • Caregivers • Representatives of Consumers • Activists • Associations - AARP

18. Providers of Care • Physicians • Nurses, PAs, Others (SW, Pharm, RDs, PTs) • Diagnostic and Laboratory Technicians • Associations / Trade Organizations

19. Institutions that Provide Care • Hospitals, Medical Centers • Specialty Clinics • Rehab • Drug / Substance Abuse • Long-term care facilities • Associations • American Hospital Association

20. Government : Federal, State, Local • Regulatory Role • Political Process - set regulations, respond to electorate • Reimbursement • Medicare, Medicaid (States) • Public Health System

21. Insurance Groups • Blues • Associations / Trade Organizations

22. Support Industries • Pharmaceutical Companies and Distributors • Medical Devices • Medical Equipment

23. Employers • Economists • Judiciary; Legal Support • Information / Technology Industry • WebMD; Drugstore.com • Higher Education

24. Components of Health Care • Consumers - Insurance • Providers of Care - Government • Institutions that provide care - Employers • Support Industries • Economists / Financing • Information / Technology • Higher Education

25. SOCIETY • Components of Health Care

26. 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

27. Health Insurance Plans • Traditional Care / Fee-for-Service • Health Maintenance Organizations • Preferred Provider Organizations • Medicare • Medicaid • Disability Insurance • Hospital Indemnity Insurance • Long Term Care

28. 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;

29. 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

30. 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

31. Preferred Provider Organizations • Combination of a fee-for-service and HMO • Limits choice of doctors / hospitals

32. 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

33. 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

34. 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

35. Medicaid • Title XIX of the Social Security Act - law in 1965 • Administered by the States

36. 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

37. 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

38. 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

39. ‘Medigap’ Insurance that covers expenses outside of Medicare

40. What does this mean for medical fees? • Consider billing • What the client gets billed depends on the health care plan.

41. 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.

42. 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

43. Current Issues • Government Reimbursement Rates • State and Federal Government not paying the actual • cost of care for their beneficiaries • * HMOs are dropping Medicare beneficiaries

44. 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

45. 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

46. 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 thereare only 3.

47. 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

48. 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

49. 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