Your SlideShare is downloading. ×
Health Care Costs, Access And Financing
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Health Care Costs, Access And Financing

652

Published on

Published in: Health & Medicine
0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
652
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
43
Comments
0
Likes
2
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide
  • Transcript

    • 1. Health Care Cost, Access and Financing John Brill, MD, MPH 1969: $268 1990: $2567 2000: $5712 2004: $6280
    • 2. Goals
      • Increase awareness of health care costs and national responses to increases
      • Increase knowledge of funding mechanisms and programs
      • Promote concern about the costs of health care we provide and control
    • 3. Why Should You Care?
    • 4. Why Should You Care
      • Because otherwise politicians will!
      • Because you pay for health care too
      • Because costs for health care effect the cost of other goods and services
      • Because you can make a difference
      • Because it might effect your income
      • Because it matters to your patients (at least some of them)
    • 5. Overview
      • Health Care Costs
        • National Perspective
        • Clinician Perspective
        • Personal Perspective
      • Health Care Financing: Who/What/Where/How Much/Why
    • 6. Costs
      • How much?
      • How does the US compare to other countries?
      • History of costs
      • Responses to Rising Costs
    • 7. Approximately how much was spent on health care in the United States in 2004? A. $1.9 Billion B . $19 Billion C. $190 Billion D . $1.9 Trillion
    • 8. What % of the United States Gross Domestic Product (GDP) is spent on health care? A. 6% B. 11% C. 16% D. 21% E. 26%
    • 9. According to health care economist Victor Fuchs [JAMA 269 631 (1993)] and other experts, which of the following is most responsible for the high costs of health care in the US? A . Treating ‘hopeless’ cases at the end of life B . Americans’ demand for the best care available C . Malpractice and ‘defensive medicine’ D. Fraud and Abuse in health care
    • 10. Measuring Health Care Costs
      • Annual Expenditures
      • % Gross Domestic Product (GDP)
    • 11.  
    • 12. Per Capita HC Costs (Unadjusted)
      • 1969: $268
      • 1990: $2567
      • 2000: $5712
      • 2004: $6280
    • 13. International Health Care Spending (As % GDP)                                                                                           
    • 14. Reasons for Rising Costs
      • Aging
      • 3rd Party Payers
      • Malpractice/Defensive Medicine
      • Fraud/Waste
      • Administrative Costs
      • Futile Care
      • Technology
    • 15. Responses to Rising Costs
      • Managed Care
      • Malpractice Reform
      • Medical Savings Accounts
    • 16. Managed Care
      • History: Early 1970s--rising costs, threatened national health insurance
      • 1973 HMO Act--gov’t subsidies for HMO start-ups (IT’S NIXON’S FAULT!)
      • 1976: 6 million HMO enrollees
      • 1991: 38 million HMO enrollees
    • 17. Managed Care--How does it save money?
      • Gatekeeper
      • Utilization Review
      • Prior Authorization
      • Evidence-based practice/Pathways
      • Provider ‘Deselection’
      • Exclusions
    • 18. Malpractice Reforms
      • Reducing Filing of Claims
      • Limiting the Plaintiff’s Award
      • Altering the Plaintiff’s Burden of Proof
      • Changing the Judicial Role
    • 19. Medical Savings Accounts
      • Premise: Individuals spend their own money more wisely than someone else’s
      • Example: Employer contributes $3000 per year to MSA; Employee gets to keep unused remainder
      • Problem: 17% of persons would exceed $3000, accounting for 86% of health care expenditures
    • 20. FUNDING AND ACCESS
      • History of Insurance in US
      • Payers
      • Uninsured/Underinsured
    • 21.  
    • 22.  
    • 23.  
    • 24. Where does the Money Come From?
    • 25. Where does the money go?
    • 26. Health Insurance in US
      • 1850: First health insurance policy in US
      • 1929: Dallas teachers directly contract with Baylor Hospital for services at preset monthly cost--start of Blue Cross plans
      • WW II: Offered as employee benefit in Portland shipyards; by 1955, 77 million Americans insured through employer
      • 1965 Medicare
      • 1966 Medicaid
    • 27. Employee-Sponsored Health Insurance
      • History: Portland Shipyards, WWII
        • Response to cap on wages
      • The Congressional Tax Act of 1954
        • This act allowed employer contributions to life, health and disability insurance, to be tax exempt
      • Currently 74% of Employed (Dropping)
    • 28. Government programs
      • 45% of all US health care expenditures
      • Medicare
      • Medicaid
      • CHAMPUS
      • VA
      • Rapidly rising proportion of all government spending
    • 29. Medicare
      • Federal insurance program for elderly (>/= 65; 30 million and growing) and disabled (4 million and growing)
      • Part A covers Hospital
      • Part B covers Doctors
      • Part D (new in 2006) covers medications
      • 98% seniors participate
      • 70-90% have “Medigap” insurance
    • 30. Medicaid
      • Federal program for ‘deserving poor’ (but only covers 40% of persons <100% FPL)
      • Coverage and eligibility vary by state
      • Variety of programs including coverage for pregnant women, children, disabled, dialysis, long-term care (most important provider of NH coverage)
    • 31. BadgerCare
      • Wisconsin version of Child Health Insurance Program
      • Coverage for poor uninsured children and parents (“Health Insurance for Working Families”)
      • No asset test; covers up to 185% FPL (e.g. $16,500 income for family of 3)
      • Medicaid Expansion Program (coverage same as T19)
    • 32. GA-MP (General Assistance-Medical Program)
      • Milwaukee County program for uninsured, medically needy
      • Eligibility equal to ~ 130% FPL (~$800/month for single adult)
      • No mental health/substance abuse/dental coverage
      • 43% state, 58% local $$ funded
      • {citizenship}
    • 33. Wisconsin Women’s Wellness Program
      • Covers Preventive (Pap, mammos) and F/U (Colpo, biopsy) care for women
      • Income Eligibility: Up to 250% FPL
      • Age Eligibility: 45 and over; occasional exceptions
    • 34. Uninsured--How Many?
      • ~40 Million Americans (~15%) at any one time
      • Most temporary (27% Population without insurance for at least one month in 1993)
    • 35. Uninsured--Who are they?
      • 75-85% Employed-- Part-Time or Low Wage Jobs--and their dependents
      • Low-Income (50% of persons <200% FPL uninsured for at least one month/year)
      • Minorities (33% Hispanics, 23% African-Americans)
      • Non-Citizens (~15% of the Uninsured)
    • 36. Underinsured
      • ‘Significant limitations in coverage’ High deductibles (>$500/yr)
        • High Co-pays (>15%)
        • Exclusion of basic benefits (Doctor visits, prenatal care)
      • Dental, vision also frequently excluded but not included in definition
      • ~30 Million Americans, growing rapidly
      • (274 JAMA 1302, 1995)
    • 37. Can you make a difference? 40 y/o man with essential HTN is started on medications
      • Grab a sample of CCB
      • Cost: $50/month
      • Lifetime cost (30 years x $60/yr -1 month samples) =$18,000
      • Less proven benefits
      • Start HCTZ
      • Cost $5/month
      • Lifetime Cost (30 years x $60/yr) =$1800
      • More proven benefits
    • 38. Can you make a difference II 20 y/o woman comes in with frequent headaches:
      • Order MRI
      • Cost: $3200 (AHC bill to insurance)
      • If clinician sees 50 headaches/year total cost =
      • $160,0000
      • Advise to drink extra 1.5l water/day
      • Cost: $0-2.50
      • Little harm and RCT evidence of benefit
    • 39. Does it matter to you?
      • The Impact of Health Insurance
      • costs on day-to-day life
    • 40.  
    • 41. In the 1980s the U.S. auto manufacturers started to pay more for healthcare for their employees per car, than steel per car . In 1996 GM paid $1200 in health costs per car, and foreign auto manufacturers spend as little as $100, due to younger, healthier workers, and lack of retirees. Kleinke, J.D., The Bleeding Edge ,
    • 42. Alphabet Soup
    • 43.  
    • 44. HMO (Health Maintenance Organization)
      • Either discounted fee-for-service or capitated payment to in-plan providers, only emergency coverage for out-of-plan providers. Generally need referral.
      • Local Examples:
        • Compcare, Humana, MHS
      • Point Of Service (POS) plans: allow enrollees to see out-of-plan providers but at substantially higher copays/deductibles. May still need referral.
    • 45.
      • Discounted fee-for-service among in-plan providers. Usually can see any provider without referral.
      • Local Example:
        • Some Blue Cross (Anthem) Plans
      PPO (Preferred Provider Organization)
    • 46. Indemnity Insurance
      • Traditional “fee-for-service,” widest range of provider choices but most expensive
      • Example:
        • Blue Cross/Blue Shield (Anthem)
    • 47. PHO (Physician Hospital Organization)
      • Structure in which a hospital and physicians negotiate as an entity directly with insurers.
      • Local Example:
        • MCW/Froedtert Practice Plan
    • 48. IPA (Independent Practice Association)
      • HMO that contracts with individual/groups of physicians to provider services on a capitated or discounted fee-for-service basis.
      • Local Example:
        • West Allis Physicians’ Association
    • 49. Physician Billing and Payment
      • Coding – diagnosis (ICD) & procedure (CPT)
      • Current procedural terminology (AMA)
      • Relative Value Units (RVU)
      • Conversion factor (dollars per RVU)
      • Payment = RVU x CF = $
    • 50. Relative Value Scales (RVS)
      • Comparative values of all physician procedures
      • Historically developed and evolved
      • Resource Based Relative Value Scale (RBRVS – 1992)
    • 51. Elements of RBRVS
      • Time
      • Training
      • Intensity
      • Malpractice
      • Overhead
      Work
    • 52. Sample RVU
      • 99214 Office Visit Established; Level 4
      • Work RVU – 1.10
      • Overhead
        • Non-facility – 1.05; facility – 0.40
      • Malpractice – 0.05
      • Total non-facility – 2.20
      • Total facility – 1.55
      • Medicare conversion factor – 37.3374
      • Medicare allowable fee – $82.14 (non-facility); $57.87 (facility)
    • 53. What Does Physician Collect? *Non-Medicare Assignment 0 7.00 0 8.20* Bill Patient 90.00 110.00 56.00 82.00 TOTAL 72.00 88.00 56.00 65.60 Insurance Pays 18.00 22.00 0 16.40 Patient Co-Pay 90.00 110.00 56.00 82.00 Allowable PPO Indemnity Medicaid Medicare
    • 54.  
    • 55. Evaluation and Management CPT - Documentation
        • History
          • HPI; ROS; PFSH
        • Exam
          • Areas of body
        • Decision making
          • Number of diagnoses
          • Complexity of data
          • Level of risk to patient
        • Typical time
    • 56. Physician Compensation
          • Salary vs. incentives
          • Incentive methods
            • Percentage of collections (billings)
            • RVU methods
            • Capitation distribution
            • Quality bonuses
          • Multispecialty sharing

    ×