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

Health Care Costs, Access And Financing

on

  • 1,268 views

 

Statistics

Views

Total Views
1,268
Slideshare-icon Views on SlideShare
1,268
Embed Views
0

Actions

Likes
0
Downloads
40
Comments
0

0 Embeds 0

No embeds

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

Health Care Costs, Access And Financing Health Care Costs, Access And Financing Presentation Transcript

  • Health Care Cost, Access and Financing John Brill, MD, MPH 1969: $268 1990: $2567 2000: $5712 2004: $6280
  • 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
  • Why Should You Care?
  • 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)
  • Overview
    • Health Care Costs
      • National Perspective
      • Clinician Perspective
      • Personal Perspective
    • Health Care Financing: Who/What/Where/How Much/Why
  • Costs
    • How much?
    • How does the US compare to other countries?
    • History of costs
    • Responses to Rising Costs
  • 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
  • What % of the United States Gross Domestic Product (GDP) is spent on health care? A. 6% B. 11% C. 16% D. 21% E. 26%
  • 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
  • Measuring Health Care Costs
    • Annual Expenditures
    • % Gross Domestic Product (GDP)
  •  
  • Per Capita HC Costs (Unadjusted)
    • 1969: $268
    • 1990: $2567
    • 2000: $5712
    • 2004: $6280
  • International Health Care Spending (As % GDP)                                                                                           
  • Reasons for Rising Costs
    • Aging
    • 3rd Party Payers
    • Malpractice/Defensive Medicine
    • Fraud/Waste
    • Administrative Costs
    • Futile Care
    • Technology
  • Responses to Rising Costs
    • Managed Care
    • Malpractice Reform
    • Medical Savings Accounts
  • 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
  • Managed Care--How does it save money?
    • Gatekeeper
    • Utilization Review
    • Prior Authorization
    • Evidence-based practice/Pathways
    • Provider ‘Deselection’
    • Exclusions
  • Malpractice Reforms
    • Reducing Filing of Claims
    • Limiting the Plaintiff’s Award
    • Altering the Plaintiff’s Burden of Proof
    • Changing the Judicial Role
  • 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
  • FUNDING AND ACCESS
    • History of Insurance in US
    • Payers
    • Uninsured/Underinsured
  •  
  •  
  •  
  • Where does the Money Come From?
  • Where does the money go?
  • 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
  • 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)
  • Government programs
    • 45% of all US health care expenditures
    • Medicare
    • Medicaid
    • CHAMPUS
    • VA
    • Rapidly rising proportion of all government spending
  • 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
  • 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)
  • 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)
  • 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}
  • 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
  • Uninsured--How Many?
    • ~40 Million Americans (~15%) at any one time
    • Most temporary (27% Population without insurance for at least one month in 1993)
  • 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)
  • 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)
  • 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
  • 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
  • Does it matter to you?
    • The Impact of Health Insurance
    • costs on day-to-day life
  •  
  • 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 ,
  • Alphabet Soup
  •  
  • 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.
    • 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)
  • Indemnity Insurance
    • Traditional “fee-for-service,” widest range of provider choices but most expensive
    • Example:
      • Blue Cross/Blue Shield (Anthem)
  • PHO (Physician Hospital Organization)
    • Structure in which a hospital and physicians negotiate as an entity directly with insurers.
    • Local Example:
      • MCW/Froedtert Practice Plan
  • 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
  • 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 = $
  • Relative Value Scales (RVS)
    • Comparative values of all physician procedures
    • Historically developed and evolved
    • Resource Based Relative Value Scale (RBRVS – 1992)
  • Elements of RBRVS
    • Time
    • Training
    • Intensity
    • Malpractice
    • Overhead
    Work
  • 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)
  • 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
  •  
  • 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
  • Physician Compensation
        • Salary vs. incentives
        • Incentive methods
          • Percentage of collections (billings)
          • RVU methods
          • Capitation distribution
          • Quality bonuses
        • Multispecialty sharing