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Health Care in Texas -- Assumptions, Structure & Change by Tim Schauer
Health Care in Texas -- Assumptions, Structure & Change by Tim Schauer
Health Care in Texas -- Assumptions, Structure & Change by Tim Schauer
Health Care in Texas -- Assumptions, Structure & Change by Tim Schauer
Health Care in Texas -- Assumptions, Structure & Change by Tim Schauer
Health Care in Texas -- Assumptions, Structure & Change by Tim Schauer
Health Care in Texas -- Assumptions, Structure & Change by Tim Schauer
Health Care in Texas -- Assumptions, Structure & Change by Tim Schauer
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Health Care in Texas -- Assumptions, Structure & Change by Tim Schauer

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A look at five historical assumptions ...

A look at five historical assumptions ...

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  • 1. June 13, 2014 by Tim Schauer Health Care in Texas Assumptions, Structure And Change
  • 2. Historical Assumptions 1. People get sick and hurt 2. Health care is not a “Free Market” 3. We strive to be a civilized society 4. Complexity makes health care a difficult political issue 5. Health care is evolving
  • 3. #5 - Evolution of Health Care • Change drivers: – Cost of care – Health care inflation rolls on… – Innovations – Science, R&D, Business models… – Expectations – Patients, Providers, Public… – Governance – Who is accountable??? – Laws – Major changes to the rules of the game: • M/M in 1965 • ERISA in 1974 • SSRA (PPS) in 1983 • COBRA in 1985 • EMTALA in 1986 • HIPAA in 1996 • BBA in 1997 • ACA in 2010
  • 4. The People of Texas (74% Insured, 26% Uninsured) County Government State of Texas US Government Hospitals (Public) MDs Clinics Ancillary Services Taxes Hospitals (Private) Hospital District, CIHCP Med Schools HHSC Medicaid/CHIP DSHS, DADS, DARS, DFPS DSH and 1115 Waiver CMSDHHS Traditional Medicaid FMAP Match Star and Star+Plus ESI via small business ESI via big business (ERISA) Premiums Medicare (plus Advantage) DOL TDI Individual Insurance (FFE) *** All boxes of this color pay for health services via patient claims processing with some level of managed care strategies
  • 5. #1 - Sick and Hurt • All humans will get sick and/or hurt at some point in their lifetimes. • Risk management can be approached in fundamentally two ways: • Wait for something to happen, respond; then figure out how to pay for it afterwards. • Plan for it, insure it (share the risk), and manage the response when it happens.
  • 6. #2 - Not a “Free Market” • No resale market • No power to repossess for lack of payment • Poorly informed consumer choices – Little to no input on disease, ailment or injury – Who wants cheap health care? – Personal relationship with MDs – Price transparency challenges
  • 7. #3 - Civilized Society • We want to live healthy, happy and safe • We love children, the elderly and people with disabilities (somewhat) • We want to cure disease and ease suffering • It is uncivilized to let people die in the streets
  • 8. #4 - Complexity • Difficult for individuals and families when they need care – rely on the experts (MDs) • Uncompensated care – the uninsured – cause financial contortions for the system • R&D in medicine makes it difficult to keep up • Public health and wellness help prevention but do not eliminate #1 • Sound-bites are rarely correct or helpful in health policy discussions

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