Nursing fund


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  • Source: Health Care Financing Administration, Office of the Actuary. Data are published in the Health Care Financing Review, and in
    Health Affairs (usually the January/February issue) and they are also on the web at
  • Source: Center for Medicare & Medicaid Services, Office of the Actuary, National Health Statistical Group.
    Note: BBA is Balanced Budget Act.
  • Source: Health Care Financing Administration, Office of the Actuary, data from the National Health Statistics Group.
    Note: Other health services include dental services, other professions, durable medical equipment, over-the-counter medical products, home
    health services, other personal health care, program administration, and the net cost of insurance, government public health activities, research,
    and construction.
    Personal Health Care: 1130.4
  • Source: Health Care Financing Administration, Office of the Actuary. Data are published in the Health Care Financing Review, and inHealth Affairs (usually the January/February issue) and they are also on the web at
  • Source: Employee Benefit Research Institute: Data based on March CPS Survey.
  • *Includes those receiving coverage from other public programs as well as those in non-risk HMOs.
    SOURCE: Barents Group of KPMG Consulting’s analysis of the 1999 Medicare Current Beneficiary Survey.
  • Medicare: Medicare finances part of the care of the elderly (those eligible for Social Security), some of the permanently and totally disabled, and most people with end stage renal disease (kidney failure). It is a federal program. It is funded through payroll taxes (Part A), general tax revenue and premiums (Part B) and beneficiary cost sharing.
    Medicaid: This is a federally sponsored and state administered program that pays for health care services for the indigent. Subject to broad federal guidelines, the states have considerable discretion in determining who is eligible for the program, what services and providers will be covered, and how much they will pay, to providers for rendering care.
  • Public State and Local: This includes the total amount spent by the state and local authorities for health care. It included the state share of Medicaid plus budget allocations to public hospitals to cover the cost of providing care to the poor not covered by Medicaid.
  • Source: Health Care Financing Administration, Office of the Actuary. Data are published in the Health Care Financing Review, and in
    Health Affairs (usually the January/February issue) and they are also on the web at
  • Medicare Physician Fee Schedule
    Private Plans
    Negotiated prices
    BIdding for business
    Control Over Total Expenditures
    Medicaid HMOs
    Medicare Risk Contracts
    Private Sector HMOs
    Expenditure Targets
  • Source: Health Care Financing Review: Medicare and Medicaid Statistical Supplemental, 2000, p. 32.
    Note: There were 38.8 million Medicare Beneficiaries in 1998. Therefore, only 75% of them received any payment by Medicare.
  • Nursing fund

    1. 1. Issues Related to Health Care Financing Overview of the size and growth of the health care sector The distribution of personal health care services Flow of Funds for Health Care Nature of Financing Decisions Judith R. Lave, Ph. D. January 2004 Brought to you by
    2. 2. Share of National Health Expenditures, By Type 2002 Total (Billions) $1,553 Total 100% Personal Health Services 86.3 Prog. Admins + Net Cost of Health Insurance 6.8 Research & Construction 3.6 Public Health 3.3 Per Capita Expenditures $5,440 Brought to you by
    3. 3. Notes on Data Summary Information: Jan/Feb Issues of Health Affairs (K. Levit et al. Health Spending Rebound Continues. Health Affairs. 23(1), 2004. Complete Search: National Health Expenditures, Click: Health Accounts. Click: Tables Brought to you by
    4. 4. Annual Percent Change in National Health Spending Selected Years Current Dollars 1970-1980 12.9% 1980-1988 10.8 1988-1993 9.3 1993-1997 5.3 1997-2000 6.2 200-2001 8.5 2001-2002 9.3 Brought to you by
    5. 5. Many Definitions of Healthcare Costs Healthcare Expenditures (p x q) Prices of Individual Services Premiums for Health Insurance Out-of-Pocket Payments % of GDP to Health Care (14.9%) Brought to you by
    6. 6. National Health Expenditures as a Percent of GDP 1970-2010 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 Accelerated growth Managed care and BBA impacts: “one- time” effects on price and volume levels Moderate Growth Brought to you by
    7. 7. Distribution Expenditures on Personal Health Care 2002 Prescription drugs 12.1%10.4% Nursing-- home care 25.3% Physician & Clinical Services 36.3% Hospitals 15.9% Other health services Brought to you by
    8. 8. Percentage Change in Expenditures 2000-20002 Category Percent Change 2000-2001 2001-2002 Overall 8.5% 9.3% Hospital Care 7.5 9.5 Physician and Clinical Services 8.5 7.7 Nursing Home&Home Health 5.8 4.9 Prescription Drugs 15.9 15.3 Brought to you by
    9. 9. prem ium s, general taxes, payroll taxes, state lotteries Households Tax payers The Financing of Health Care out-of-pocket payments fee-for-service, budgets,capitation medical services “claim s”Financing Side Reimbursement Side Third Parties Government Agencies Insurance Companies (Health Plans) prem ium s, general taxes, payroll taxes Providers (doctors, hospitals, dentists, etc.) Patients Employers Employees
    10. 10. Nonelderly Americans With Selected Sources on Health Insurance Coverage: 2002 Type of Coverage % of nonelderly population * Employment-Based Coverage Individually Purchased Public Medicare Medicaid Tricare/CHAMPVA No Health Insurance 64.2 6.7 15.9 2.3 11.9 2.8 17.3 Population: 250.8 million * Does not add up to 100% because people can have more than one source of health insurance Brought to you by
    11. 11. Sources of Supplemental Coverage: Among Non-Institutional Medicare Beneficiaries: 1999 Other* 2% Medicare Only 13% Employer- Sponsored 33% Medicaid 11% Medigap 24% Medicare HMOs 17% Total = 34.7 million non-institutional Medicare beneficiaries Brought to you by
    12. 12. No Standard Health Plan Health Insurance Policies Vary With Respect to: covered services covered providers administrative terms under which services are accessed methods for paying providers Brought to you by
    13. 13. Importance of Insurance Coverage Use of services is a function of price (which depends on insurance structure and coverage) (i.e., Claritin) Decisions to cover or not cover certain providers/technologies/services can make or break an industry (i.e., physical therapy, mammograms, obesity surgery) Medicare is often pace-maker on ways to pay providers Brought to you by
    14. 14. Brief Discussion of Health Care Financing Terms Insurance policies vary considerably. They vary with respect to which services will be covered, how much cost sharing will be borne by the policy holder, administration conditions under which consumers/patients access care, what providers will be covered, how much providers will be paid. Private Health Insurance: Health insurance is purchased in the market by groups (either through the place of business or through professional associations) or by individuals. The premium is the price paid for the insurance policy. Under employer sponsored group health insurance plans, the cost of the premiums is paid in whole or in part by the employer. Brought to you by
    15. 15. Definitions of Terms in the Following Charts Direct Patient Payments: This is the total amount paid out of pocket by the patient or by the patient’s family for a given service. Private Third Parties: This is the total amount paid for a given service on the behalf of the consumer or services. This would include payments made by blue cross, blue shield, a health maintenance organization, Aetna, etc. Public Federal: This is the total amount paid by the federal government for health care. It includes expenditures made under Medicare, Medicaid, The Veteran’s Administration, etc. Brought to you by
    16. 16. National Health Expenditures By Source of Funds Selected Calendar Years 1970-2002 32.530.929.024.0Federal 45.944.042.637.8Public Funds 13.716.523.734.3Out of Pocket Payments Funds 35.433.627.721.2Private Health Insurance 13.413.113.613.7State & Local 100%100%100%100%Total 2002199319801970Source of Payment Brought to you by
    17. 17. Percent of Personal Health Care Expenditures Paid Out of Pocket 1990 2002 Total 22.6% 15.8% Hospital 4.4 3.0 Physician & clinical services 20.5 10.1 Nursing Home care 40.4 25.1 Dental 48.3 44.0 Prescription Drugs 55.8* 30.0 *This is for 1992 Brought to you by
    18. 18. Source of Payment for Personal Healthcare: Percent Distribution for Selected Services (2002) Note: only selected sources enumerated Medicaid (Fed & State) Medi- care Out of Pocket Private Insu- rance Total PrivateTotal Expendi- tures (billions) Type of Service 49.312.525.17.535.9100.0%103.2 Nursing Home Care Prescription Drugs (99) 5.4….44.049.593.6100.0%70.3 Dental Services (99) 12.420.310.149.266.2100.0%339.5 Physician Services Hospital Care 17.419.315.835.855.8100.0%$1,340.2 Total Personal Healthcare GovernmentPrivate Source of Expenditure (%)
    19. 19. What are some of the problems that people have with current insurance? Brought to you by
    20. 20. Employer Sponsored Health Insurance 90% of Private Health Insurance Obtained Through Employer Employer Share of Premium Excluded from Taxes Employer Selects Plan Who Bears the Cost? Economists: The Employee in lower wages Others: The Employer in lower profits Brought to you by
    21. 21. Question What are the advantages/disadvantage s of getting health insurance through the employer? Brought to you by
    22. 22. New Wrinkle Defined Contribution 1. Pay same amount towards all plans offered by employer. 2. Pay employee fixed amount divided between cash and a catastrophic cap. Employee selects a plan from a network of providers. 3. Pay employee fixed amount to purchase insurance privately. Brought to you by
    23. 23. A Very Conservative Position Decide how much you want to subsidize health care—who do you want to help? Get rid of the incentives that encourage people to obtain their health insurance through their employers. Eliminate the tax subsidy of employer based health insurance: treat all health insurance equally—probably with a tax credit. Let people use their own dollars to purchase medical care/insurance—let them make their own trade-offs. (could be defined contribution) Note: Similar to the A.M.A. position. Brought to you by
    24. 24. Selected Policies By Third Parties Control Over Prices Government – Administered Prices –Prospective Payment System Hospitals – “DRG’s” Nursing Home – “RUG’s” Home Health Agencies – “HHRG” Outpatient Department – - “APC” Rehabilitation Facilities – “FIM- FRG” DRG = Diagnoses Related Group RUG = Resource Related Group HHRG = Home Health Related Group APC = Ambulatory Patient Classification FIM-FRG = Functional Independence Measure- Function Related Group Brought to you by
    25. 25. Development of Managed Care Strongly Encouraged By Capitation Selection of Physician/Providers who Practice Cost-Effectiveness Care Capitation of Primary Care (Gate- Keeper and Other Providers) Utilization Management Care management Preadmission screening Concurrent review Guidelines Disease management Introduction of Best Practices Brought to you by
    26. 26. 35.0% 27.6% 13.8% 8.4% 9.20% 6.10% 7.7% 5.1% 10.3% 25.8% 49.9% Percent Distribution of Medicare Enrollees an Program Payments Under Medicare: CY 1998 29.3 Million Enrollees $168.2 Billion in Program Payments Percent of Persons Served Percent of Program Payments $25,000 or More $10,000-24,999 $5,000-9,999 $2,000-4,999 $25,000 or More $10,000-24,999 $5,000-9,999 $2,000-4,999 $500-1,999 $1-499 AmountofProgramPayments $500-1,999 Brought to you by
    27. 27. Please help us We need funds, guide us
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