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Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
Us Healthcare Presentation
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Us Healthcare Presentation

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A brief history & explanation of the U.S. Healthcare system given to Fellows & students.

A brief history & explanation of the U.S. Healthcare system given to Fellows & students.

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  • Why start with Winston Churchill? Because England, like every other modern industrialized nation but ours, differs from us in the way they have all chosen to provide healthcare to their citizens. This decision has given us a complicated, expensive, and by many measures a deeply flawed system. This talk however will not debate that issue. Michael Moore’s recent movie “Sicko” has done a pretty good job illustrating some of these problems. Instead, I will give a brief discussion of our system as it exists now and ideally provide you with the background you should have in order to function adequately within it.
  • Transcript

    • 1. Evan J. Silbert, M.P.A. UCLA-Gonda Diabetes Center The U.S. Healthcare System A Beginner’s Guide Introduction <ul><li>“ You can always rely on the Americans to do the right thing, after they've exhausted all other options.” -Winston Churchill </li></ul>
    • 2. Overview <ul><li>Other industrialized nations </li></ul><ul><li>Centralized/socialized government provided/supervised </li></ul><ul><li>USA </li></ul><ul><li>De-centralized primarily market based </li></ul>
    • 3. The Mechanics Not fun, easy, or exciting, but it’s all we’ve got <ul><li>Players </li></ul><ul><ul><li>Doctors </li></ul></ul><ul><ul><li>Hospitals </li></ul></ul><ul><ul><li>Insurers </li></ul></ul><ul><ul><li>Big Pharma </li></ul></ul><ul><ul><li>DME Providers </li></ul></ul><ul><ul><li>SNFs & ECFs </li></ul></ul><ul><ul><li>Ambulances </li></ul></ul><ul><ul><li>Governments </li></ul></ul><ul><ul><ul><li>State & Federal </li></ul></ul></ul><ul><ul><li>Oh yeah, patients ! </li></ul></ul>
    • 4. The Basic Mechanics The encounter The order(s) The bill The payment
    • 5. Health Insurance: Risk v. Reward
    • 6. The U.S. Health Insurance Industry <ul><li>Profitable, for a reason! </li></ul>
    • 7. The Concept of Risk <ul><li>DOUBLE INDEMNITY </li></ul><ul><li>Written by James Mc Cain </li></ul><ul><li>Screenplay: Billy Wilder </li></ul>Keyes turns to Neff and gives him the lecture of his life! KEYES You've never read an actuarial table in your life, have you? Why, we've got ten volumes on suicide alone. Suicide by race, by color, by occupation, by sex, by seasons of the year, by time of day. Suicide, how committed -- by poisons, by firearms, by drowning, by leaps, by poison; by types of poison, such as corrosive, irritant, systemic, gaseous, narcotic, alkaloid, protein and so forth. Suicide by leaps! Subdivided by leaps from high places; under the wheels of trains, under the wheels of trucks, under the feet of horses! From steamboats!
    • 8. Medicare <ul><li>“ Medicare will free millions from their miseries. It will signal a deep and lasting change in the American way of life. It will take its place beside Social Security, and together they will form the twin pillars of protection upon which all people can safely build their lives and hopes.” </li></ul><ul><li>-President Lyndon B. Johnson, July 12, 1965 </li></ul>&quot; . . . behind it will come other Federal programs that will invade every area of freedom as we have known it in this country. Until one day, as Norman Thomas said, we will awake to find that we have socialism. And if you don't do this and if I don't do it, one of these days you and I are going to spend our sunset years telling our children and our children's children what it once was like in America when men were free.” -Ronald Reagan, official spokesman for the AMA, 1963
    • 9. Medicare <ul><li>Part A: HOSPITAL INSURANCE </li></ul><ul><li>Usually no monthly premium </li></ul><ul><li>Part B: MEDICAL INSURANCE </li></ul><ul><li>Monthly premium ( Starting January 1, 2007, the Part B premium is based on income. Most people pay the standard monthly Part B premium of $93.50 in 2007). </li></ul><ul><li>Part D: DRUG PLAN </li></ul><ul><li>Additional monthly premium </li></ul><ul><li>Medicare is </li></ul><ul><li>A health insurance program for people: </li></ul><ul><ul><li>Age 65 and older </li></ul></ul><ul><ul><li>Some people with disabilities under age 65 </li></ul></ul><ul><ul><li>People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant). </li></ul></ul><ul><li>Part C: MEDICARE ADVANTAGE PLANS </li></ul><ul><li>Those with Part A and Part B </li></ul><ul><li>Managed Plans administered by private insurers, e.g.: </li></ul><ul><ul><li>Secure Horizons </li></ul></ul>
    • 10. Medicaid <ul><li>Medicaid is </li></ul><ul><li>A program created by Title XIX of the Social Security Act that provides coverage for acute and long term services to 52 million Americans, including low income children, parents, seniors and people with disabilities. </li></ul><ul><li>State administered, governed by federal AND state rules and JOINTLY funded with federal and state dollars </li></ul><ul><li>An entitlement program that requires federal and state governments to SPEND THE FUNDS NECESSARY to operate mandatory program components. </li></ul><ul><li>The nation’s largest purchaser of health services, collectively spending just over $317 billion in FY 2005 in federal and state dollars. </li></ul><ul><li>2007 California HealthCare Foundation </li></ul>
    • 11. Medi-Cal <ul><li>Medi-Cal and Medicare are two separate health insurance programs. Medicare is health insurance that comes through Social Security benefits and requires the payment of monthly premiums, deductibles and, by choice, coinsurance for many of its benefits. </li></ul><ul><li>Medi-Cal, on the other hand, is not tied to Social Security benefits and does not require payment of premiums or deductibles. It provides 100%, comprehensive coverage of most medical expenses. In addition, health care providers who accept Medi-Cal can't bill for any additional charges as they can under Medicare </li></ul>Nearly half of California's primary care physicians (45 percent) and specialists (43 percent) say they do not have any Medi-Cal patients in their practices, according to a new report published by the California HealthCare Foundation's Medi-Cal Policy Institute (MCPI). Medi-Cal, California's version of the federal Medicaid program for low-income families and elderly and disabled individuals, pays for health services for 6.1 million Californians. Conducted by the University of California, San Francisco in 1998. <ul><li>Medi-Cal is </li></ul><ul><li>The nation’s largest Medicaid program in terms of the number of people it serves (6.6 million) and is the second largest in terms of dollars spent ($40 billion) </li></ul><ul><li>The source of health coverage for nearly 1 in 5 Californians under age 65 </li></ul><ul><li>The source of health coverage for 1 in 3 California children </li></ul><ul><li>The source of health coverage for the majority of Californians with AIDS </li></ul><ul><li>The payer for nearly 46% of all births in California </li></ul><ul><li>The payer for two thirds of all California nursing home residents. </li></ul>
    • 12. Private Insurers <ul><li>Most Americans have health insurance through their employers. </li></ul>Nearly 47 million Americans, or 16 percent of the population, were without health insurance in 2005. DeNavas-Walt, C.B. Proctor, and C.H. Lee. Income, Poverty, and Health Insurance Coverage in the United States: 2005 . U.S. Census Bureau. , August 2006. <ul><li>Types of coverage </li></ul><ul><li>Indemnity: </li></ul><ul><li>PPO, EPO, CDHP </li></ul><ul><li>2. Managed Care: </li></ul><ul><li>HMO, POS </li></ul><ul><li>3. Workers’ Compensation </li></ul>
    • 13. Private Insurers What do employees prefer? <ul><li>Most employers who offer health benefits to their </li></ul><ul><li>employees offer only one plan. </li></ul><ul><li>According to a 1997 survey of employer health </li></ul><ul><li>insurance supported by the Robert Wood Johnson </li></ul><ul><li>Foundation, only 17% of those employers providing </li></ul><ul><li>health benefits offer their employeesa choice between </li></ul><ul><li>two or more plans. </li></ul><ul><li>Although larger firms are more likely to offer their </li></ul><ul><li>employees a choice, the survey found that </li></ul><ul><li>only one-third of firms with 100 or more employees </li></ul><ul><li>offer a choice of plans. </li></ul><ul><li>On the employee side, less than one-half (41%) of </li></ul><ul><li>employees who are offered insurance by their employer can </li></ul><ul><li>choose among two or more plans. </li></ul><ul><li>Rethinking Health Insurance </li></ul><ul><li>The AMA’s Proposal for Reforming the Private Health </li></ul><ul><li>Insurance System </li></ul><ul><li>AMA Health Policy Group, 1999. </li></ul>
    • 14. Straight Indemnity “The good ol’ days” <ul><li>Indemnity plans are the “traditional” form of health insurance. There are no restrictions on which doctor, hospital, or other provider a patient may see. The insurer usually pays the provider directly (if they accept assignment). Most indemnity plans cover a specific percentage of what are called the usual, customary and reasonable expenses after a deductible. The patient is responsible for the balance. </li></ul>
    • 15. Preferred Providers <ul><li>Preferred Provider Organization </li></ul><ul><li>An organization that represents a group of providers who have negotiated their rates for treatment with various health plans. </li></ul><ul><li>Beyond office visits, there are usually utilization controls for additional goods and services (Pre-Authorizations) </li></ul><ul><li>Patients choosing to use non-PPO providers (“out of network”) usually encounter higher co-payments, deductibles, and higher co-insurance rates (e.g. patient’s payment percentage responsibility is higher). </li></ul>
    • 16. Preferred Providers <ul><li>Exclusive Provider Organization </li></ul><ul><li>(EPO) plan is very similar to an HMO: </li></ul><ul><ul><li>With an EPO, patient must select a primary care physician or physician gatekeeper who coordinates care </li></ul></ul><ul><ul><li>Out-of-network care is not covered (“closed panel”) </li></ul></ul><ul><li>Providers typically offer deeper discounts on their rates because (in theory) they will see a higher volume of patients </li></ul>
    • 17. Preferred Providers <ul><li>Consumer Directed Health Plan (CDHP): </li></ul><ul><li>The underlying premise: </li></ul><ul><li>Employees must take more responsibility for their health care decisions. </li></ul><ul><li>Provide information about providers and treatments, use enhanced Internet tools and, perhaps, most importantly, giving patients a greater financial stake in care decisions . </li></ul><ul><li>Typically defined as a high-deductible health plan combined with a tax-advantaged savings account—usually either a health reimbursement arrangement (HRA) or a health savings account (HSA). </li></ul><ul><li>HRAs are owned and funded solely by employers. </li></ul><ul><li>HSAs are employee-owned and fully portable (employer contributions are optional). </li></ul>For both types of accounts, the plan deductible typically exceeds the employer contribution to the spending account, leaving the employee at risk for higher out-of-pocket costs. To be eligible for an HSA, the person must have a health insurance plan with a specified high deductible, while employers offering HRAs have more flexibility.
    • 18. Managed Care: HMOs <ul><li>HMO — Health Maintenance Organization: A broad term that, in general, refers to any organized plan other than a traditional health insurance company that provides health care services. Some plans are very tightly structured so that all care is provided by the HMO's employees in the HMO's hospitals or clinics, while other plans are cooperative agreements among independent doctors, hospitals and other health care providers. </li></ul>
    • 19. Brief History <ul><li>Early “Prepaid” practice types </li></ul><ul><ul><li>1929 Dr. Michael Shadid starts a rural farmer’s cooperative in Elk City Oklahoma with help from the Oklahoma Farmers’ Union enrolls several hundred families </li></ul></ul><ul><ul><li>1929 the L.A.D.W.P. contracts with Drs. Donald Ross and H. Clifford Loos to provide prepaid care to their employees and families </li></ul></ul><ul><ul><li>1933 Dr. Sidney Garfield (also in L.A.) contracts to provide prepaid care to 5,000 L.A. Aqueduct Construction workers. </li></ul></ul><ul><ul><li>Henry Kaiser sets up 2 prepaid programs on the west coast to provide comprehensive health care to his steel mill and shipyard workers during WWII. </li></ul></ul><ul><ul><ul><li>After the war, opens the Plans to the public </li></ul></ul></ul><ul><ul><ul><li>10 years later, Kaiser-Permanente had a network of clinics and hospitals with an enrollment of 500,000 </li></ul></ul></ul><ul><ul><ul><li>Tufts Managed Care Institute </li></ul></ul></ul><ul><ul><ul><li>A Brief History of Managed Care, 1998 </li></ul></ul></ul>
    • 20. Brief History <ul><li>Modern HMO period </li></ul><ul><ul><li>The Nixon Administration passes The HMO Act of 1973 </li></ul></ul><ul><ul><ul><li>$375 million provided to: </li></ul></ul></ul><ul><ul><ul><ul><li>Develop HMOs </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Exempt them from any State laws prohibiting prepaid groups </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Mandate that employers with > 25 employees offer a federally qualified HMO to their employees IF the HMO asked to be offered. </li></ul></ul></ul></ul><ul><ul><ul><li>Tufts Managed Care Institute </li></ul></ul></ul><ul><ul><ul><li>A Brief History of Managed Care, 1998 </li></ul></ul></ul>
    • 21. Basic Mechanics <ul><li>HMO structure </li></ul><ul><ul><li>“ STAFF” model </li></ul></ul><ul><ul><ul><li>Kasier Permanente </li></ul></ul></ul><ul><ul><li>“ CONTRACT” model </li></ul></ul><ul><ul><ul><li>Insurers (HealthNet, UnitedHealthCare, Blue Cross) </li></ul></ul></ul><ul><ul><ul><li>Knox-Keene licensed entities (Molina Medical) </li></ul></ul></ul><ul><li>HMO Process </li></ul><ul><ul><li>Enrollee (“member”) </li></ul></ul><ul><ul><ul><li>Chooses a Primary Care Physician (PCP) who guides their care </li></ul></ul></ul><ul><ul><ul><li>Usually needs a “Referral/Authorization” to obtain additional care and/or services </li></ul></ul></ul><ul><ul><li>PCP </li></ul></ul><ul><ul><ul><li>Manages the care and treatment of the members assigned to them </li></ul></ul></ul>
    • 22. Workers’ Compensation <ul><li>Separate and Distinct </li></ul><ul><li>State mandated for all employers </li></ul><ul><ul><li>Provided privately & by State </li></ul></ul><ul><ul><ul><li>SCIF </li></ul></ul></ul><ul><li>Envisioned as a trade-off: </li></ul><ul><li>Employers agree to provide all reasonable and necessary care to employees injured at work </li></ul><ul><li>Employees generally agree to forego their right to sue for the tort of negligence, “pain and suffering”, and punitive damages. </li></ul><ul><li>Physician Involvement </li></ul><ul><li>Usually over </li></ul><ul><ul><li>AOE/COE </li></ul></ul><ul><ul><ul><li>(Arising out of employment)/Course of Employment) </li></ul></ul></ul><ul><ul><li>Extent of any Permanent Disability </li></ul></ul>
    • 23. Reimbursement Structures <ul><li>FFS (Fee-for-service) </li></ul><ul><li>Managed Care types </li></ul><ul><ul><li>Capitation </li></ul></ul><ul><ul><ul><li>Percent of Premium </li></ul></ul></ul><ul><ul><ul><li>Risk sharing </li></ul></ul></ul><ul><ul><li>Reduced FFS </li></ul></ul><ul><ul><li>% of Medicare </li></ul></ul><ul><ul><li>Stop-Loss </li></ul></ul>
    • 24. Capitation (per head) <ul><li>Per member per month (PMPM) </li></ul><ul><li>Carve outs </li></ul><ul><ul><li>AIDS </li></ul></ul><ul><ul><li>HIGH PRICED DRUGS </li></ul></ul><ul><ul><li>TRANSPLANTS </li></ul></ul><ul><ul><li>MENTAL HEALTH </li></ul></ul><ul><ul><ul><li>Alcohol/Drug Rehab </li></ul></ul></ul>
    • 25. Capitation (per head) <ul><li>Risk Sharing </li></ul><ul><ul><li>Establish a “pool” for payment of certain expenses and share anything that’s left </li></ul></ul><ul><ul><ul><li>May have to “pony up” if the pool runs dry </li></ul></ul></ul><ul><ul><ul><ul><li>In-patient days </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Rx </li></ul></ul></ul></ul><ul><li>% of Premium </li></ul><ul><ul><li>Commercial </li></ul></ul><ul><ul><li>Medicare </li></ul></ul><ul><ul><ul><li>Experience rating </li></ul></ul></ul><ul><ul><li>Medi-Cal </li></ul></ul><ul><li>Stop-Loss </li></ul>
    • 26. CODING What I did and why I did it Each year, in the United States, health care insurers process over 5 billion claims for payment. Centers for Medicare and Medicaid Services, 2006
    • 27. The NPI National Provider Identifier <ul><li>Mandated by HIPAA Regulation </li></ul><ul><li>Required for all covered Health Care Providers </li></ul><ul><li>A 10 digit “intelligence free code” </li></ul>The numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. Apply for yours by completing the CMS-10114-NPI form at: http://www.cms.hhs.gov/cmsforms/downloads/CMS10114.pdf
    • 28. Reporting Schema <ul><li>What I did </li></ul><ul><ul><li>Common Procedural Terminology (CPT) </li></ul></ul><ul><ul><ul><li>Maintained and copyrighted by the AMA </li></ul></ul></ul><ul><ul><ul><li>AMA receives a License Fee for their use </li></ul></ul></ul><ul><li>Why I did it </li></ul><ul><ul><li>The International Classification of Diseases (ICD) </li></ul></ul><ul><ul><ul><li>Originated and maintained by the World Health Organization </li></ul></ul></ul><ul><ul><ul><li>Medicare currently uses the 9th Edition </li></ul></ul></ul>
    • 29. The Others <ul><li>HCPCS </li></ul><ul><li>The Healthcare Common Procedure Coding System (pronounced &quot;hick-picks&quot;) was originally created for use under the Medicare program. </li></ul><ul><li>Level I - CPT ® codes (see above) </li></ul><ul><li>Level II - National Codes (i.e., &quot;J&quot; codes, &quot;A&quot; codes, &quot;Q&quot; codes, &quot;C&quot; codes for OPPS only) </li></ul><ul><li>Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office. </li></ul><ul><li>Level II HCPCS codes were established for submitting claims for these items. Level II codes are also referred to as alpha-numeric codes because they consist of a single alphabetical letter followed by 4 numeric digits, while CPT codes are identified using 5 numeric digits. </li></ul>
    • 30. The Others <ul><li>DSM </li></ul><ul><li>Diagnostic and Statistical Manual of Mental Disorders ( DSM </li></ul><ul><li>DSM-IV  and DSM-IV-TR codes are valid ICD-9-CM codes. </li></ul><ul><li>ICD-9-CM Volume 3 </li></ul><ul><li>Procedure Codes </li></ul><ul><li>The Procedure Classes are created to facilitate health services research on hospital procedures using administrative data. This classification system allows the researcher to readily determine if (a) a procedure is diagnostic or therapeutic, and (b) a procedure is minor or major in terms of invasiveness and/or resource use. </li></ul>
    • 31. The Others <ul><li>ICD-9-CM Volume 3 </li></ul><ul><li>Procedure Codes </li></ul><ul><li>The Procedure Classes are created to facilitate health services research on hospital procedures using administrative data. </li></ul><ul><li>Researcher to readily determine if (a) a procedure is diagnostic or therapeutic, and (b) a procedure is minor or major in terms of invasiveness and/or resource use. </li></ul><ul><li>Minor Diagnostic - Non-operating room procedures that are diagnostic (e.g., CT scan of head) </li></ul><ul><li>Minor Therapeutic - Non-operating room procedures that are therapeutic (e.g., Irrigate ventricular shunt) </li></ul><ul><li>Major Diagnostic - All procedures considered valid operating room procedures by the Diagnosis Related Group (DRG) grouper and that are performed for diagnostic reasons (e.g., Open brain biopsy) </li></ul><ul><li>Major Therapeutic - All procedures considered valid operating room procedures by the Diagnosis Related Group (DRG) grouper and that are performed for therapeutic reasons (e.g., Aorta-renal bypass). </li></ul><ul><li>Healthcare Cost and Utilization Project (HCUP) </li></ul>
    • 32. Service/Goods/Facilities America's Health Insurance Plans, a trade group for the managed care industry, said that a survey of its members found that 75 percent of current claims were now electronic, compared with 44 percent four years ago. New York Times, May 26, 2006
    • 33. Service/Goods/Facilities UB04 Facility type claims Cover a period. Revenue Codes Developed by the American Hospital Association, to bill services, drugs, and supplies furnished in the hospital. These lines shows the total for ALL the charges for that type of service in that period. Prospective Payment Systems DRG In-Patient: Diagnosis Related Group APC Outpatient: Ambulatory Payment Classification Per-Diems
    • 34. Service/Goods/Facilities RBRVS Resource Based Relative Value Scale President George H.W. Bush Omnibus Budget Reconciliation Act, 1989 1988- Dr. William Hsaio Harvard University Relative Values Assigned - Physician Work - Practice Expense Facility Non-Facility - Malpractice Geographically adjusted - GPCI (“gypsy”) CMS 1500 (08/05)
    • 35. Relative Value Update Committee Determines the Resource Based Relative Value for each new code and revalues all existing codes at least once every five years. The RUC has 29 members, 23 of whom are appointed by major national medical societies. The six remaining seats are held by the Chair (an AMA appointee), an AMA representative, a representative from the CPT Editorial Panel, a representative from the American Osteopathic Association, a representative from the Health Care Professions Advisory Committee and a representative from the Practice Expense Review Committee. Who Decides?
    • 36. How do I use it? Find the CPT code It’s on the CMS web site: http://www.cms.hhs.gov/PhysicianFeeSched/
    • 37. How do I use it? Determine the GPCI (Geographic Practice Cost Index) for each RVU It’s on the CMS web site: http://www.cms.hhs.gov/PhysicianFeeSched/
    • 38. How do I use it? Multiply the RVUs by their GPCIs Multiple the WORK result by the Budget Neutrality Factor
    • 39. How do I use it? Add the adjusted RVU totals
    • 40. How do I use it? Multiply the adjusted RVU total by the National Conversion Factor and you’re done!
    • 41. or, you can go to: http://www.medicarenhic.com/cal_prov/fee_sched.shtml And download the fee schedule!
    • 42. Evan J. Silbert, M.P.A. UCLA-Gonda Diabetes Center The U.S. Healthcare System A Beginner’s Guide Conclusion <ul><li>“ It's not enough that we do our best; sometimes we have to do what's required.” -Winston Churchill </li></ul>

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