This chapter discusses the financing of healthcare in the United States. It covers the major sources of healthcare funding such as private insurance, Medicare, and Medicaid. It also examines trends like the increasing role of managed care plans and high-deductible plans. The chapter analyzes factors driving rising healthcare costs in the US compared to other countries. It also reviews ongoing efforts to reduce waste, fraud, and abuse, as well as link payments to quality of care.
mHealth Israel_US Health Insurance Overview- An Insider's PerspectiveLevi Shapiro
Presentation about the US Health Insurance Sector by Lori Rund, VP, Product Management and Market Intelligence at Health Alliance Plan, a managed care organization owned by the Henry Ford Health System, with 650,000 lives. Lori is responsible for the identification, concept building, researching and business case developments for new products, services and markets. She develops and leads comprehensive market intelligence functions to help the organization better understand industry trends and identify business opportunities.
Prior to joining Health Alliance Plan, Lori was Director of Product Development and Market Intelligence at Health Alliance Medical Plans in Illinois and Director of Market Research and Strategy at Carle Clinic Association, also in Illinois.
The changing landscape of health care in the US -- drivers and outcomesGregory Travis
The United States has the worst health care outcomes among its OECD peers. It also has the highest health care costs within the OECD. What are the reasons for this and what changes can we anticipate going forward?
hapter 5What Are the Governmental AlternativesThe United StatJeanmarieColbert3
hapter 5
What Are the Governmental Alternatives?
The United States has tried an alphabet soup of health policy options: HSAs, HMOs, IPAs, PPOs, POS plans, ACOs, and so on. Health care analysts often must look beyond specific organizational and financial alternatives and address issues at a higher level and deal with the threads of economic and political thought behind different proposals while considering the overall criteria of access, cost, and quality of care.
Politicians and businesspeople from outside the health care sector advocate many alternatives. To offset their tendency to ignore professional issues, in this chapter we discuss alternatives affecting professional status and roles and institutional responses to them. Table 5-1 presents an array of federal alternatives organized by their primary criteria—access, quality, or cost—and then by the economic philosophies behind them. The items in this array are not intended to be either mutually exclusive or collectively exhaustive; rather, the table provides a framework for looking at both the broad policy picture and specific health care actions taken at various times and places. Later in the chapter, another table (Table 5-3) summarizes policy alternatives added by state and local governments. Many of these alternatives were included as provisions of the Affordable Care Act (ACA). They are still included here, partly because they may be subject to reconsideration in the future.
Table 5-1 Illustrative Federal Government Health Policy Options
Access to Care
• Administered systems
• Universal coverage
• Expand or reduce eligibility or benefits
• Mandate coverage and services
• Captive providers
• Control insurance industry practices
• Mandate employer-based insurance coverage
• Consumer-driven competition
• Implement insurance exchanges
• Encourage basic plans with very low premiums for low-income workers and “young invincibles”
• Mandate individual coverage
• Allow states flexibility to reallocate federal funds for vouchers
• Oligopolistic competition
• Expand or contract coverages in entitlement and categorical programs
• Allow states to reallocate federal uncompensated care funds
• Eliminate ERISA constraints on the states
• Expand the capacity of the system
Quality of Care
• Administered system
• Mandate participation in quality improvement efforts in federal plans and programs
• Add more pay-for-performance incentives
• Select providers and programs on the basis of quality excellence
• Consumer-driven competition
• Encourage or mandate transparency of quality reporting in federal plans and programs
• Oversee licensure and credentialing of foreign-trained providers
• Oligopolistic competition
• Work reporting of quality care and adverse events into purchasing specifications for federal programs and disseminate to the public
• Encourage wider use of health information technology
Cost of Care
• Administered system
• Use full bargaining power in negotiation of ...
mHealth Israel_US Health Insurance Overview- An Insider's PerspectiveLevi Shapiro
Presentation about the US Health Insurance Sector by Lori Rund, VP, Product Management and Market Intelligence at Health Alliance Plan, a managed care organization owned by the Henry Ford Health System, with 650,000 lives. Lori is responsible for the identification, concept building, researching and business case developments for new products, services and markets. She develops and leads comprehensive market intelligence functions to help the organization better understand industry trends and identify business opportunities.
Prior to joining Health Alliance Plan, Lori was Director of Product Development and Market Intelligence at Health Alliance Medical Plans in Illinois and Director of Market Research and Strategy at Carle Clinic Association, also in Illinois.
The changing landscape of health care in the US -- drivers and outcomesGregory Travis
The United States has the worst health care outcomes among its OECD peers. It also has the highest health care costs within the OECD. What are the reasons for this and what changes can we anticipate going forward?
hapter 5What Are the Governmental AlternativesThe United StatJeanmarieColbert3
hapter 5
What Are the Governmental Alternatives?
The United States has tried an alphabet soup of health policy options: HSAs, HMOs, IPAs, PPOs, POS plans, ACOs, and so on. Health care analysts often must look beyond specific organizational and financial alternatives and address issues at a higher level and deal with the threads of economic and political thought behind different proposals while considering the overall criteria of access, cost, and quality of care.
Politicians and businesspeople from outside the health care sector advocate many alternatives. To offset their tendency to ignore professional issues, in this chapter we discuss alternatives affecting professional status and roles and institutional responses to them. Table 5-1 presents an array of federal alternatives organized by their primary criteria—access, quality, or cost—and then by the economic philosophies behind them. The items in this array are not intended to be either mutually exclusive or collectively exhaustive; rather, the table provides a framework for looking at both the broad policy picture and specific health care actions taken at various times and places. Later in the chapter, another table (Table 5-3) summarizes policy alternatives added by state and local governments. Many of these alternatives were included as provisions of the Affordable Care Act (ACA). They are still included here, partly because they may be subject to reconsideration in the future.
Table 5-1 Illustrative Federal Government Health Policy Options
Access to Care
• Administered systems
• Universal coverage
• Expand or reduce eligibility or benefits
• Mandate coverage and services
• Captive providers
• Control insurance industry practices
• Mandate employer-based insurance coverage
• Consumer-driven competition
• Implement insurance exchanges
• Encourage basic plans with very low premiums for low-income workers and “young invincibles”
• Mandate individual coverage
• Allow states flexibility to reallocate federal funds for vouchers
• Oligopolistic competition
• Expand or contract coverages in entitlement and categorical programs
• Allow states to reallocate federal uncompensated care funds
• Eliminate ERISA constraints on the states
• Expand the capacity of the system
Quality of Care
• Administered system
• Mandate participation in quality improvement efforts in federal plans and programs
• Add more pay-for-performance incentives
• Select providers and programs on the basis of quality excellence
• Consumer-driven competition
• Encourage or mandate transparency of quality reporting in federal plans and programs
• Oversee licensure and credentialing of foreign-trained providers
• Oligopolistic competition
• Work reporting of quality care and adverse events into purchasing specifications for federal programs and disseminate to the public
• Encourage wider use of health information technology
Cost of Care
• Administered system
• Use full bargaining power in negotiation of ...
Imagine a healthcare system where people live long, healthy lives, receiving quality, affordable care, with clinicians nationwide collaborating to improve outcomes. That's Accountable Care! Learn the benefits of becoming an ACO in this insightful eBook.
Managed Care within Health Care covers a variety of information from nursing homes, policies, Medical, Medicare, out of pocket, and partial payment, management, contracts, government, and the Social Security State Fund. Within this working paper I will discuss a few of these mechanisms that are applied and utilized within ‘Managed Care’ today. A system within a system that brings in 25% of the United States debt.
The Affordable Care Act: Success or Failure?
Janet Coffman, MPP, PhD
Edward Yelin, PhD
GME Grand Rounds 4/15/14
UCSF San Francisco
http://medschool2.ucsf.edu/gme/
DQ 3-2Integrated health care delivery systems (IDS) was develope.docxelinoraudley582231
DQ 3-2
Integrated health care delivery systems (IDS) was developed to initiate excellence health care access and quality of care to entire populations and community by collaborating and coordinating diverse healthcare professionals. Main driving force of IDS is patient centered care by using resources such as collaborating care from physicians and allied health care professionals to construct continuum of care, to deliver care in the most cost-effective way, utilize trained and competent providers by utilizing evidenced -based practice and combine innovation such as EHR (Electronic Health Records) system and team work to produce improved healthcare system.
Excellence in care is attainable by incorporating allied healthcare professional, as high quality care is possible when coordination is unified and covers all areas of responsibilities. For an example-combining resources and coordination of care by involving physicians, dietitian, physical therapy or occupational therapy to work with patient diagnosed with obesity by promoting teamwork approach and ultimately delivering endurance in care and utilizing various resources.
Barriers to IDS can be a huge block in delivering quality care. Among many one limitation is physicians not participating in integrated healthcare system, which disconnect physicians from team based approached by deterring continuous quality improvement (essentialhospitals.org, n.d). This is because, system such as EHR or new innovative quality assurance programs are time consuming and overwhelming, thus decline in physicians support in IDS programs. By implementing user friendly system approach, enforcing focused based care and accepting the necessity of evidenced based practice can improve these barriers. Hence, increasing clinical expertise to produce better service and quality of care in integrated delivery system.
Essentialhospitls.org (n.d). Retrieved from: http://essentialhospitals.org/wp-content/uploads/2013/12/Integrated-Health-Care-Literature-Review-Webpost-8-22-13-CB.pdf
Dq 3-1
1.
In the US, there is not one type of health care system but rather a subset of systems, some of them catering to specific populations. These subsystems include managed care, military, and vulnerable populations. Managed care is a health care delivery system that seeks to achieve efficiency by integrating the basic functions of health care delivery, employs mechanisms to control utilization of medical services, and determines the price at which the services are purchased and how much the providers get paid, military health care system is available free of charge to active duty military personnel and covers preventative and treatment services that are provided by salaried health care personnel and this system combines public health with medical services, and vulnerable population subsystem offers comprehensive medical and enabling services targeted to the needs of vulnerable populations and government health insurance programs provide.
HCL's transformational Patient's first approach to HealthcareDebanjan Munsi
Digital Care management is the new buzzword in Healthcare technology, with the advent of digital technologies that track patient health, medicine subscriptions, dosages and create customized tracking, monitoring & delivery programs with regular dosage reminders, data driven insights on health vitals and patient routing to best possible treatment locations. Digital care management can not only reduce costs, but increase the vitality of healthcare programs, making them more efficient, decisive and customer friendly.
COST FACTORS & STRATEGIESReasons for increasing costs of healt.docxvanesaburnand
COST FACTORS & STRATEGIES
Reasons for increasing costs of health care and
Some strategies for managing them
Page
No.
(1)
Admin/
Providers’
Strategies
(2)
Gov’t &
Payors' Strategies
(3)
Societal Factors
Which Increase
Costs
Advanced Technology
Aging Population
AIDS
Capitation
Cardiac Catheterization Lab
Care Mapping/Clinical Pathways
Case Rates and Per Diems
CAT Scanner
Change of Reimbursement System from Charge-Based, to Cost-Based, to Flat-Fee to Capitation
CON (Certificate of Need)
Concurrent Review
Cost Shifting
Cost Accounting System
Deductibles and Co-Payments
Defensive Medicine
Gatekeepers
Global Payments/ Bundling of Services
Increased Chronic, Long-Term Illnesses
Increased Long-Term Care
Inflation
Information Systems Technology
Joint Replacements
Just-in-Time Delivery
Large Jury Awards
Litigation
Medicaid Tightened Eligibility Restrictions
Mergers and Acquisitions
MRI
Neonatal ICU
Organ Transplants
Part-Time Workers Replacing Full-Time Workers
Payment System
Penalties for Services Outside of HMO Network w/o Prior Approval
Point of Care
Preadmission Certification and Second Opinions
Prospective Payment (DRG)
Prospective Payments
Provider Networks
Reengineering/Redesign
Retrospective Review
Rising Expectations
Shift to Outpatient Services
Steerage and Discounts
The Uninsured
Total Quality Management
NAME OF STUDENT:
�Introduction�
Never before have health care professionals faced such complex issues and practical dif-
ficulties trying to keep their organizations financially viable (see Perspective 1–1). With
C h a p t e r O n e
THE CONTEXT OF HEALTH CARE
FINANCIAL MANAGEMENT
Learning Objectives
AAfftteerr ccoommpplleettiinngg tthhiiss cchhaapptteerr,, yyoouu wwiillll bbee aabbllee ttoo::
� Identify key factors that have led to rising health care costs.
� Identify key approaches to controlling health care costs.
� Identify key ethical issues resulting from attempts to control costs.
Introduction
Rising Health Care Costs
The Payment System
Technology
The Aging Population
Prescription Drugs
Chronic Diseases
Compliance and Litigation
The Uninsured
Efforts to Control Costs
Efforts by Payors to Control Health Care
Costs
DRGs
Capitation
Global Payments
APCs
Cutting Delivery Costs
Shift to Outpatient Services
Cost Accounting Systems
Information Services Technology
Mergers and Acquisitions
Reengineering/Redesign
Cost Control Issues with Ethical
Overtones
Summary
Key Terms
Chapter Outline
063123098X-01.qxd 9/11/02 6:34 PM Page 1
turbulent changes taking place in payment, delivery, and social systems, health care pro-
fessionals are faced with trying to meet their organization’s health-related mission in an
environment of extreme cost pressure. In order to provide a context for the topics covered
in this text, .
A look at the top healthcare issues affecting healthcare providers and consumers in 2019 and beyond. Payment and practice patterns shifts are affecting when, where and how healthcare consumers are accessing and paying for care. Healthcare technology is fueling the change as providers struggle to keep pace and deliver high patient satisfaction and engagement. Consumer demands are growing as more of the cost burden is shifted to the employee as employer sponsored health plans see an unprecedented shift in the way they provide care for employees.
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
Imagine a healthcare system where people live long, healthy lives, receiving quality, affordable care, with clinicians nationwide collaborating to improve outcomes. That's Accountable Care! Learn the benefits of becoming an ACO in this insightful eBook.
Managed Care within Health Care covers a variety of information from nursing homes, policies, Medical, Medicare, out of pocket, and partial payment, management, contracts, government, and the Social Security State Fund. Within this working paper I will discuss a few of these mechanisms that are applied and utilized within ‘Managed Care’ today. A system within a system that brings in 25% of the United States debt.
The Affordable Care Act: Success or Failure?
Janet Coffman, MPP, PhD
Edward Yelin, PhD
GME Grand Rounds 4/15/14
UCSF San Francisco
http://medschool2.ucsf.edu/gme/
DQ 3-2Integrated health care delivery systems (IDS) was develope.docxelinoraudley582231
DQ 3-2
Integrated health care delivery systems (IDS) was developed to initiate excellence health care access and quality of care to entire populations and community by collaborating and coordinating diverse healthcare professionals. Main driving force of IDS is patient centered care by using resources such as collaborating care from physicians and allied health care professionals to construct continuum of care, to deliver care in the most cost-effective way, utilize trained and competent providers by utilizing evidenced -based practice and combine innovation such as EHR (Electronic Health Records) system and team work to produce improved healthcare system.
Excellence in care is attainable by incorporating allied healthcare professional, as high quality care is possible when coordination is unified and covers all areas of responsibilities. For an example-combining resources and coordination of care by involving physicians, dietitian, physical therapy or occupational therapy to work with patient diagnosed with obesity by promoting teamwork approach and ultimately delivering endurance in care and utilizing various resources.
Barriers to IDS can be a huge block in delivering quality care. Among many one limitation is physicians not participating in integrated healthcare system, which disconnect physicians from team based approached by deterring continuous quality improvement (essentialhospitals.org, n.d). This is because, system such as EHR or new innovative quality assurance programs are time consuming and overwhelming, thus decline in physicians support in IDS programs. By implementing user friendly system approach, enforcing focused based care and accepting the necessity of evidenced based practice can improve these barriers. Hence, increasing clinical expertise to produce better service and quality of care in integrated delivery system.
Essentialhospitls.org (n.d). Retrieved from: http://essentialhospitals.org/wp-content/uploads/2013/12/Integrated-Health-Care-Literature-Review-Webpost-8-22-13-CB.pdf
Dq 3-1
1.
In the US, there is not one type of health care system but rather a subset of systems, some of them catering to specific populations. These subsystems include managed care, military, and vulnerable populations. Managed care is a health care delivery system that seeks to achieve efficiency by integrating the basic functions of health care delivery, employs mechanisms to control utilization of medical services, and determines the price at which the services are purchased and how much the providers get paid, military health care system is available free of charge to active duty military personnel and covers preventative and treatment services that are provided by salaried health care personnel and this system combines public health with medical services, and vulnerable population subsystem offers comprehensive medical and enabling services targeted to the needs of vulnerable populations and government health insurance programs provide.
HCL's transformational Patient's first approach to HealthcareDebanjan Munsi
Digital Care management is the new buzzword in Healthcare technology, with the advent of digital technologies that track patient health, medicine subscriptions, dosages and create customized tracking, monitoring & delivery programs with regular dosage reminders, data driven insights on health vitals and patient routing to best possible treatment locations. Digital care management can not only reduce costs, but increase the vitality of healthcare programs, making them more efficient, decisive and customer friendly.
COST FACTORS & STRATEGIESReasons for increasing costs of healt.docxvanesaburnand
COST FACTORS & STRATEGIES
Reasons for increasing costs of health care and
Some strategies for managing them
Page
No.
(1)
Admin/
Providers’
Strategies
(2)
Gov’t &
Payors' Strategies
(3)
Societal Factors
Which Increase
Costs
Advanced Technology
Aging Population
AIDS
Capitation
Cardiac Catheterization Lab
Care Mapping/Clinical Pathways
Case Rates and Per Diems
CAT Scanner
Change of Reimbursement System from Charge-Based, to Cost-Based, to Flat-Fee to Capitation
CON (Certificate of Need)
Concurrent Review
Cost Shifting
Cost Accounting System
Deductibles and Co-Payments
Defensive Medicine
Gatekeepers
Global Payments/ Bundling of Services
Increased Chronic, Long-Term Illnesses
Increased Long-Term Care
Inflation
Information Systems Technology
Joint Replacements
Just-in-Time Delivery
Large Jury Awards
Litigation
Medicaid Tightened Eligibility Restrictions
Mergers and Acquisitions
MRI
Neonatal ICU
Organ Transplants
Part-Time Workers Replacing Full-Time Workers
Payment System
Penalties for Services Outside of HMO Network w/o Prior Approval
Point of Care
Preadmission Certification and Second Opinions
Prospective Payment (DRG)
Prospective Payments
Provider Networks
Reengineering/Redesign
Retrospective Review
Rising Expectations
Shift to Outpatient Services
Steerage and Discounts
The Uninsured
Total Quality Management
NAME OF STUDENT:
�Introduction�
Never before have health care professionals faced such complex issues and practical dif-
ficulties trying to keep their organizations financially viable (see Perspective 1–1). With
C h a p t e r O n e
THE CONTEXT OF HEALTH CARE
FINANCIAL MANAGEMENT
Learning Objectives
AAfftteerr ccoommpplleettiinngg tthhiiss cchhaapptteerr,, yyoouu wwiillll bbee aabbllee ttoo::
� Identify key factors that have led to rising health care costs.
� Identify key approaches to controlling health care costs.
� Identify key ethical issues resulting from attempts to control costs.
Introduction
Rising Health Care Costs
The Payment System
Technology
The Aging Population
Prescription Drugs
Chronic Diseases
Compliance and Litigation
The Uninsured
Efforts to Control Costs
Efforts by Payors to Control Health Care
Costs
DRGs
Capitation
Global Payments
APCs
Cutting Delivery Costs
Shift to Outpatient Services
Cost Accounting Systems
Information Services Technology
Mergers and Acquisitions
Reengineering/Redesign
Cost Control Issues with Ethical
Overtones
Summary
Key Terms
Chapter Outline
063123098X-01.qxd 9/11/02 6:34 PM Page 1
turbulent changes taking place in payment, delivery, and social systems, health care pro-
fessionals are faced with trying to meet their organization’s health-related mission in an
environment of extreme cost pressure. In order to provide a context for the topics covered
in this text, .
A look at the top healthcare issues affecting healthcare providers and consumers in 2019 and beyond. Payment and practice patterns shifts are affecting when, where and how healthcare consumers are accessing and paying for care. Healthcare technology is fueling the change as providers struggle to keep pace and deliver high patient satisfaction and engagement. Consumer demands are growing as more of the cost burden is shifted to the employee as employer sponsored health plans see an unprecedented shift in the way they provide care for employees.
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
We understand the unique challenges pickleball players face and are committed to helping you stay healthy and active. In this presentation, we’ll explore the three most common pickleball injuries and provide strategies for prevention and treatment.
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
2. Chapter Objectives
• Understand the scope and magnitude of U.S.
healthcare spending in relationship with other
developed countries.
• Review evolution of the U.S. healthcare
financing system, trends, and initiatives of the
ACA of 2010 and the MACRA of 2015.
• Review ongoing efforts to link costs with quality
of care.
• Understand the related roles of government and
the private sector in financing health care and
roles of respective sector stakeholders.
3. Major Themes (1 of 2)
• Origins of U.S. healthcare financing systems
• Employer-based health insurance remains the
predominant source of health insurance for
working Americans.
• Payment for health services as a mosaic of
government and private sources
• While more than 21 million Americans gained
health insurance due to the ACA and Medicaid
expansion, millions remain uninsured
• Effects of managed care on costs, quality, and
access to health care; implications of financial
risk-sharing
4. Major Themes (2 of 2)
• Population-based, value-driven (not volume-
driven) payment
• Ongoing of cost control efforts linked with
quality
• Reasons for continued cost increases, waste,
fraud, and abuse
• Market reforms through consolidations and
mergers accommodate new payment systems
and quality requirements
• Financing experimentation through the ACA,
MACRA
5. Overview
• ACA Immediate effects, e.g., health insurance
regulations; full effects of policy changes unfold
over many years
– ACA did not change fundamental public/private
financing mechanisms of U.S. healthcare
• Most Americans’ health coverage provided by
employers’ private insurance
• Uninsured numbers increased 40+ million until
2011; immediate decrease by 1 million, due to
ACA allowing children on parents’ coverage
until age 26
6. Healthcare Expenditures in
Perspective (1 of 2)
• National healthcare expenditures reported
yearly by National Center for Health Statistics
(2014: $3 trillion+; $ 9,523/capita; 17.5% GDP;
Top personal: Hospital ($971.8 billion),
physicians + clinical services ($603.7 billion)
prescription drugs ($297.7 billion)
• Top 2011 payment sources: Private health
insurance ($991 billion); Medicare ($618.7
billion); Medicaid ($495.8 billion); all public
sources = 43% of total payments (see Figures
and Tables)
7. Healthcare Expenditures in
Perspective (2 of 2)
• Expenditure growth rate outstrips general
inflation by large margins—unsustainable
• Among 12 other developed nations, U.S. has
largest percentage of national economy
devoted to health, but lower life expectancy and
health outcomes
– U.S. GDP is 50% higher than next largest spender,
twice that of the U.K. and five times France’s per
capita costs; others use more health services, more
technology at lower costs
– U.S. spends far less on social services
8. Waste, Fraud, Abuse
• “Waste” = 30–40% total U.S. health care
spending: $476–$992 billion/year
• Causes:
– Failures in care delivery
– Failures in care coordination
– Overtreatment
– Administrative complexity
– Overpricing
• Fraud, abuse = $75–250 billion/year
– FBI, DOJ, OIG, states’
prevention/prosecution
9. Drivers of Healthcare Expenditures
• Aging population: Longevity = hospital care,
drugs; unrestricted high cost interventions
• Medical technology: Diagnostic, treatment
equipment, and pharmaceuticals; specialties
• Un- and under-insured
• Fee-for-service reimbursement creates
incentives for high volume
• Labor intensity
10. Blue Cross, Blue Shield, and
Commercial Health Insurance (1 of 3)
• Insurance payments began in 1930s with
BC hospital coverage
– Antithetical to “insurance” to guard against
unlikely events, health insurance pays for
both routine and unexpected events
– Blue Shield for physician payment followed
in 1940s
• Coverage paid whatever was billed;
prevailed 1930s–1980s until introduction
of prospective payment (DRGs) and
managed care
11. Blue Cross, Blue Shield, and
Commercial Health Insurance (2 of 3)
• “Blues” put hospital and physician care
within all working Americans’ reach w/o
financial worry
• Silenced lobbying for “universal
coverage”
• Elective hospital admissions skyrocketed
12. Blue Cross, Blue Shield, and
Commercial Health Insurance (3 of 3)
• Community-rated insurance: Premiums
set for defined groups w/o regard to age,
gender, occupation, or health status
• Experience-rated insurance: Premiums
based on historical patterns of service use
• Commercial insurers (for-profit) entered
market in late 1940s; experience-rated
competitive premiums
13. Transformation of Health
Insurance: Managed Care (1 of 5)
• Managed Care (MCOs)
– Cost increases, quality concerns → Nixon
administration enacted Health Maintenance
Organization Act (HMO) Act of 1973 with
loans, grants
– Combined insurance and health care
delivery organizations; focus on cost
containment and quality; emphases on
primary care and prevention
14. Transformation of Health
Insurance: Managed Care (2 of 5)
• Financial risk sharing
– Providers: Capitation pays pre-set, per-
member-per-month amount whether or not
services are used; physicians spending
lesser amounts retain profits, exceeding
amounts incurs penalty
– Consumers: Co-payments by visit;
deductibles require pre-determined out-of-
pocket expenditures before insurance
coverage begins; encourage consumer cost-
consciousness
15. Transformation of Health
Insurance: Managed Care (3 of 5)
– Staff model: Employed physicians in HMO-
owned facilities
– Independent practice association:
Independent physicians contracted to
provide services
• MCO payment population-based:
– Pre-payment for groups, encourage cost-
conscious care
– Actuarially determines projected service use
for age, gender, occupation, other factors to
estimate expected costs and set premiums
16. Transformation of Health
Insurance: Managed Care (4 of 5)
• Hybrid MCO Plans, for example:
– Preferred Provider Organizations (PPOs)
formed by physicians and hospitals to serve
private payers and self-insured organizations:
guarantee volume of business to hospitals and
physicians in return for fee discounts; in 2015,
56% of covered employees in large firms; 41%
of workers in small firms
– Point of Service Plans (POS) allow members
to use providers outside networks at increased
co-pays and deductibles
17. Transformation of Health
Insurance: Managed Care (5 of 5)
• Early 1990s: Average annual healthcare cost
growth declined; after initial decline, cost growth
surged as markets consolidated
• Staff model fell to virtual non-existence
• Research analysis: MCOs did not change clinical
practice, reduce costs, improve quality; more
changes needed: information systems,
appropriate incentives, revised clinical processes
• Late 1990s “backlash”: Laws in all states to
protect rights of consumers and providers against
MCO restrictions
18. High-Deductible Health Plans
• Response to managed care “backlash” to allow
more employee choice of health insurance
plans
– Entice employees with lower premiums in exchange
for out-of-pocket expenses before insurance pays
– Today, 2nd most common type of employer plans—
24% of U.S. workers select this option
– Since 2009, the percent of employees covered by
HDHPs has tripled
– IRS governs plan parameters and “portability”
between employers
19. Managed Care Today
• More than 75% of employees covered by
employer health insurance (111 million)
are enrolled in managed care plans
• 2016: 31% of 57 million Americans
covered by Medicare are enrolled in
Medicare Advantage managed care (17+
million)
• 2014: 77% of Medicaid beneficiaries (55.2
million) are enrolled in managed care
20. Managed Care Quality (1 of 3)
• National Committee for Quality Assurance
(NCQA): Independent, not-for-profit
organization funded by accreditation services
fees; accredits health plans serving 136+ million
Americans on voluntary basis
• NCQA services: Accreditation for MCOs, PPOs,
MBHCOs, new health plans, disease
management programs, PCMHs, etc.
• HEDIS
21. Managed Care Quality (2 of 3)
Healthcare Effectiveness Data and
Information Set (HEDIS)
• NCQA, MCOs, employer partnership: Created a
standardized method for MCOs to collect,
analyze, and report performance allowing
comparisons among MCO plans
– Criteria: Effectiveness of care; access/availability of care;
satisfaction with care; health plan business stability;
service use and cost; informed health care choices
– CMS requires all Medicare MCOs to publicly report
HEDIS data; many state Medicaid programs require
same
22. Managed Care Quality (3 of 3)
• Evidence-based clinical practice guidelines and
disease management programs (DMPs)
monitor costs and quality to avoid
exacerbations, ED use, hospitalizations
– Disease management program: System of
coordinated health care interventions and
communication for high-risk patients identified from
claims data: patient education, proactive patient
outreach, feedback to providers; research results
currently yield questionable DMP effectiveness
23. Private Health Insurance Cost
Trends
• 2005–2015, annual employer-sponsored health
insurance premiums increased 5%
– 2015: Major employee health insurance costs
substantial with deductible plans
– Employees with deductible plans increased from
55% in 2006 to 81% in 2015
– Since 2010, deductibles (out-of pocket
payments before insurance pays) increased by
67%
• Benefit “buy-downs” control rising premiums
• Wellness programs to avert illness
24. Self-Funded Insurance Programs
• Large employers collect premiums and pool
funds into accounts to pay medical claims
instead of using a commercial carrier
– Actuarial firms set premium rates; third-party firms
(TPAs) administer benefits, pay claims, collect
utilization data; TPAs may provide case
management for high-cost illnesses
– Employer advantages: Avoid commercial carrier
administrative charges, premium taxes; accrue
interest on cash reserves
25. Government as a Source of Payment:
A System in Name Only
• Early focus: Government employees, special
populations, e.g., Native Americans
• Now: Medicare, Medicaid, 9 DHHS divisions
include health professional development,
military and veterans’ health services, research.
Reimbursement mosaic: vendors/purchaser
relationships, e.g., Medicare, Medicaid
26. Medicare (1 of 3)
• 1965: Title XVIII of Social Security Act
• All Americans ≥ 65 yrs. entitled to health
insurance benefits; today, 57 million covered;
“universal coverage” for elderly; covers others
with certain health conditions
• Financed by payroll taxes
• Conceded hospital accreditation to private
sector- “Joint Commission”
• Hospital payments by local Blue Cross
intermediaries
27. Medicare (2 of 3)
• Part A (1965): Mandatory; hospital coverage,
limited-time skilled nursing care, post-
hospitalization home healthcare; funded by
payroll taxes; no cost for most
• Part B (1965): Voluntary; physician services;
outpatient hospital; end-state renal disease;
outpatient diagnostic tests, medical
equipment/supplies, certain home health
services; funded by beneficiary premiums
matched with federal revenues
28. Medicare (3 of 3)
• Part C (1997): Voluntary: managed care options
through “Medicare Advantage”; beneficiaries
may pay premium
• Part D (2003): Voluntary; prescription drug
coverage (2003); beneficiaries pay premium;
significant gaps to be closed by ACA
29. Medicare Cost Containment and
Quality: Brief History (1 of 2)
• Costs rose rapidly; early amendments added
costs; later amendments sought to control cost
growth
• 1976 study: > 10% cost increase due to service
use by older Americans; almost 66% due to
hospital payroll, non-payroll, and profits
30. Medicare Cost Containment and
Quality: Brief History (2 of 2)
• Hospital reimbursement cost-based,
retrospective; fueled utilization, hospital
expansions, technology; no incentives for
efficiency
• By 1967, healthcare expenditures rising at
double the prior rate of growth; by 1972, federal
health expenditures had risen six-fold over the
1965 level
31. Medicare Cost Containment and
Quality: 1965–1985 (1 of 5)
• Legislative, regulatory attempts to slow cost
growth, improve quality. For example:
– 1966 Comprehensive Health Planning Act
– 1972 Professional Standards Review
Organizations
– 1974 Health Planning and Resources
Development state certificates-of-need
requirements
– 1984 Professional Review Organizations, now
Quality Improvement Organizations (QIOs)
32. Medicare Cost Containment and
Quality: 1965–1985(2 of 5)
• 1980 Federal Budget Reconciliation Act sought
reduction in hospital lengths of stays through
expanded home care
– Failed to reduce hospital stays; fueled explosive
home care expenses and provider fraud/abuse
• 1983: Medicare prospective payment system
(PPS) radically altered hospital reimbursement
from retrospective to prospective basis with
Diagnosis-related Groups (DRGs)
33. Medicare Cost Containment and
Quality: 1965–1985 (3 of 5)
• DRGs: Base pre-payments on treating specific
diagnoses rather than discreet units of service;
grouped 10,000+ ICD codes into 500+ patient
categories for similar conditions and expected
resource use; DRGs include factors such as
hospital teaching status and wage levels in
specific geographic locations
• Incentive: Treatment cost lower than DRG,
hospitals retain excess as profit; treatment cost
higher than DRG, hospitals absorb excess as
loss
34. Medicare Cost Containment and
Quality: 1965–1985 (4 of 5)
DRGs (cont’d)
• Excluded teaching hospitals’ direct medical
education costs, outpatient expenses, and
capital expenditures
• By 1993, DRGs adopted by 21 state Medicaid
plans and 2/3 of Blue Cross/Blue Shield plans
• Initial concerns regarding effects on
readmission rates, mortality proved unfounded;
DRGs reduced lengths of stay and mortality
rates, slowed cost growth
35. Medicare Cost Containment and
Quality: 1965–1985 (5 of 5)
• Emergency Medical Treatment and Labor Act
(EMTALA) of 1986: To prevent hospitals from
inappropriately transferring potentially high-cost
and unprofitable DRG cases to other hospitals;
imposed stiff penalties and risk of Medicare de-
certification
• DRGs financially benefited hospitals and many
posted surpluses
36. Medicare Cost Containment and
Quality: 1986–2006 (1 of 4)
• Medicare physician fee-for-service charges un-
regulated; significant MD charge increases
legislative actions: 1984—Temporary freeze
on MD payments ineffective as MDs increased
patient visits to compensate for price reductions
• 1992: Resource-based Relative Value Scale
(RBRVS) for equitable reimbursement across
specialties, services, geographic regions;
discourage overuse of expensive services
– RBRVS continues with AMA and national medical
society input
37. Medicare Cost Containment and
Quality: 1986–2006 (2 of 4)
• PPS reforms, market competition, technology,
consumerism drove delivery changes
• National Health Security Act proposal gave
focus to rising Medicare costs, service barriers,
provider choice
• BBA of 1997: Reduce Medicare spending;
extend PPS to hospital outpatient services,
home health, skilled nursing, inpatient rehab
38. Medicare Cost Containment and
Quality: 1986–2006 (3 of 4)
• BBA: Slowed Medicare growth; enacted
Medicare Part C managed care; established
Medicare Payment Advisory Commission
(MedPAC) to monitor Medicare status
• BBA challenges: Subsequent legislation
restored some budget cuts, increased
payments to Part C managed care companies
39. Medicare Cost Containment and
Quality: 1986–2006 (4 of 4)
• 2001: Medicare “Quality Initiative” and
“Medicare Quality Monitoring System” to collect,
analyze data on all Medicare fee-for-service
beneficiaries
• 2005: “Hospital Compare” website: conformity
with evidence-based practice
– 2006: Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS) added to
“Hospital Compare” to report patient perspectives
40. Medicare Cost Containment and
Quality: 2007–Present (1 of 5)
• 2008: No Medicare payment for “Hospital
Acquired Conditions” (HACs), e.g., catheter-
related infections, foreign objects retained after
surgery, falls, other traumas sustained during
hospitalization
– No payment for “never-events”: egregious, usually
preventable errors resulting in death or significant
disability, e.g., wrong-site surgery, contaminated
drugs or devices
• 2011: Partnership for Patients—demonstration
to reduce HACs
41. Medicare Cost Containment and
Quality: 2007–Present (2 of 5)
• 2013: Bundled Payments for Care Improvement
(BPCI)—links payment to results from a
complete episode of care resulting in
hospitalization involving multiple providers
– 2016: Mandated 800 hospitals’ participation in
bundled Medicare payment for hip and knee
replacements
• 2012–2016: Comprehensive Primary Care
Initiative (CPC)—supplemental payments for
service coordination for seriously ill patients
42. Medicare Cost Containment and
Quality: 2007–Present (3 of 5)
• 2017: Comprehensive Primary Care Plus:
Five-year program using advanced primary
care medical homes; Medicare payment and
performance-based financial incentives
• 2011–2014: FQHC Advanced Primary Care
Practice Demonstration—increase quality,
reduce costs for Medicare patients
43. Medicare Cost Containment and
Quality: 2007–Present (4 of 5)
• Accountable Care Organizations (ACOs):
Private sector experiments since 1998; reduce
service fragmentation across providers; now
23+ million participants; legal entities with ≥
5000 Medicare patients; provider financial
incentives for positive patient outcomes, cost
efficiency
• Hospital Value-based Purchasing Program
(VBP): Financial incentives encourage
appropriate, efficient patient care
44. Medicare Cost Containment and
Quality: 2007–Present (5 of 5)
• Readmissions Reduction Program: Improve quality
and continuity of care post-hospitalization; financial
penalties for readmission with targeted diagnoses
within 30 days of discharge
– 2016 analysis showed readmission reductions for
both targeted and non-targeted diagnoses
• Medicare Access and CHIP Reauthorization Act
(MACRA): New “Quality Payment Program” (QPP)
with physician performance
incentives/disincentives: Merit-based and
Alternative payment models: 50% of Medicare
payments tied to APMs by 2018
45. Medicaid and the Children’s Health
Insurance Program (1 of 3)
• Medicaid: 1965, SSA Title XIX amendment
– Joint federal-state program; federal government
matches state expenses based on federal
medical assistance percentage (FMAP) adjusted
annually on states’ average personal income
– Primary source of medical coverage for low-
income, disabled Americans
– 2016: 72.4 million enrolled: low-income,
disabled adults, children, older Americans
– 19% of $2.6 trillion of personal healthcare
expenses
46. Medicaid and the Children’s Health
Insurance Program (2 of 3)
• Medicaid = 51 different programs (states +
D.C.): federal government sets broad guidelines
but states design, implement, administer
programs
– Recipients must meet financial eligibility criteria;
many work at low wages; children consume 21% of
spending; blind and disabled consume 44% of
spending
– Funded by federal matching $$ to states and state
general funds; third largest U.S. payer for health
insurance after private insurance and Medicare
• Reimbursement directly to providers; no
intermediaries
47. Medicaid and the Children’s Health
Insurance Program (3 of 3)
• Medicaid coverage types:
1. Health insurance for low-income families
w/children
2. Long-term care for older Americans
3. Supplemental coverage for low-income
Americans for services not covered by
Medicare, i.e., “dual-eligibles”
• Core federal coverage requires basic medical
services
• States may add optional benefits or extend
coverage to higher income groups
48. Children’s Health Insurance
Program
• BBA of 1997: State Children’s Health
Insurance Program (SCHIP) to enroll 10
million uninsured children
– Renamed CHIP: Largest expansion of health
insurance coverage since Medicaid in 1965
– Continuously funded: Reauthorized by ACA
until 2015; MACRA reauthorized until 2017
– Enrollment at 2014 = 8.1 million children
– 2016: 34.9 million children in Medicaid and
CHIP combined
49. Medicaid Managed Care
• Prior to 1990s, fee-for-service coverage
– State use managed care for Medicaid under
provider contracts
– MCOs receive monthly capitated payments
– 2016: ~ 2/3 Medicaid beneficiaries in private
managed care plans in 39 states and D.C.
• 2017: Federal “overhaul” to “modernize”
Medicaid managed care: supports states’
delivery system reforms with Advanced
Payment Models and increased program
transparency and accountability
50. Medicaid Quality Initiatives
• CMS Center for Medicaid and CHIP
Services: Responsibility for quality initiatives;
working partnerships with state programs
– Voluntary quality monitoring and reporting
programs with states
– Core quality standards for children’s and adult
care, including patient perspectives
• Partnership for Medicaid: Non-partisan, nationwide
coalition of physicians, other providers,
stakeholders advocate standard Medicaid quality
across all states
51. Medicaid Expansion Under the
ACA
• 2012 Supreme Court decision made states’
participation in ACA Medicaid coverage
expansion optional
– 2016: 31 states and D.C. expanded coverage
o ACA pays 100% of state expenses for newly
eligible through 2016 and drops to 90% of state
expenses by 2020 and future years
o Medicaid expansion states’ expenses dropped
significantly in 2015 due to federal funding
• Corollary effects: Streamlined Medicaid
enrollment processes, technology use,
improved reporting systems
52. Disproportionate Share Hospital
Payments (DSH)
• Since 1996, federal law requires Medicaid
payments to states (DSH) for hospitals serving
large numbers of Medicaid, low-income,
uninsured; critical support for hospitals serving
neediest populations
– Annual state DSH allotment limits total federal
contribution per hospital to 100% of costs not
covered by Medicaid; In 2015, $11.9 billion
allotment
– ACA initially reduced state allotments due to
expectation of many more insured by 2014; now,
reductions delayed to 2018
53. Individual Mandate and Health
Insurance Marketplaces (1 of 3)
• ACA requires most Americans to have health
insurance or pay a penalty: “individual
mandate” and “shared responsibility”
requirement includes:
– Employer-provided health insurance
– Medicaid
– Personally purchased health insurance policies
• Health Insurance Marketplaces (HIMs): Provide
consumers with web-based, comparative
information on health plan choices and prices
54. Individual Mandate and Health
Insurance Marketplaces (2 of 3)
• State option to create HIM
– If not, federal government established and
operated; 2016: 13 states and D.C. operated
HIMs; 34 states had federally-administered
HIMs; 4 states operated HIMs w/federal
assistance
– Federal support for HIMs through 2015;
subsequently self-sustaining
– HIMs require accessibility to 10 “essential
health benefits”
55. Individual Mandate and Health
Insurance Marketplaces (3 of 3)
• HIM participation eligibility: American
citizens and legal immigrants without
employer coverage or for whom coverage
is cost-prohibitive; acceptance
guaranteed
– Varying levels of federal financial assistance:
advance and refundable premium tax credits
and cost sharing based on personal income
56. The Employer Mandate
• Began 2015: Businesses with ≥ 50 FTE
employees must provide health insurance
to at least 95% of full-time employees and
dependents up to 26 yrs. of age or pay a
fee
– Non-compliance penalty fee (in general):
$2,000 per full-time employee (in excess of
30 employees)
57. The ACA: Insurance Coverage
Progress and Costs (1 of 2)
Coverage Progress
• Prior to ACA enactment, 48.6 million
Americans uninsured (15.7%)
– By end of 2015, 11.2 million enrolled through
HIMs; 10 million new Medicaid and CHIP
enrollees; 27 million (10%) uninsured, an
unprecedented level
– CBO projects that approx. 10% of < 65-year-
old population will remain uninsured in next
decade
58. The ACA: Insurance Coverage
Progress and Costs (2 of 2)
Costs
• 2016: Approximate net: $110 billion
• 2017–2026: Projected net: $1.4 trillion
– Annual costs: $5,000 per HIM enrollee; $
3,500 per Medicaid and CHIP enrollee
• Net costs include: Subsidies for HIM
enrollees, Medicaid and CHIP costs, tax
credits for small employers and fees,
penalties, tax revenues
59. Continuing Challenges and
Innovations
• Transforming financing system through
payment reform and population health
focus:
– New payment methods
– Departures from prior philosophies, values,
politics that fueled profit-driven waste
• Innovation by insuring millions; payment
systems linking costs with quality (e.g.,
BPCIs, ACOs, MACRA)