Public Health Chapters 26-27

• The lecture covers Public Health, specifically Chapters 26-27
• Learning objectives include analyzing primary, secondary, and tertiary care, governmental insurance systems, and employment-based health insurance
• Additional objectives are comparing health insurance options, understanding Canadian and UK healthcare systems, identifying excess costs in the U.S., and analyzing cost-reduction strategies

Primary, Secondary, and Tertiary Care

• Primary care providers are the first point of contact, handling common problems and delivering clinical preventative services
• Primary care is the foundation of the healthcare system
• A "medical home" signifies a team effort in primary care, focused on being patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety
• Six C's of Care are core values for individuals in caring industries: contact, comprehensive, coordinated, continuity, caring, and community
• Secondary care refers to specialty care, evidenced with examples of ObGyn, and anesthesiology
• Tertiary care refers to subspecialty care, often provided in academic or specialized health centers, examples are trauma center, burn center, NICU

The Six C's of Primary Care

• Contact is the entry point to the healthcare system
• Comprehensive care diagnoses and treats the majority of problems
• Coordinated care focuses diagnosis and treatment
• Continuity involves following patients over many years
• Caring means individualized care based on relationships
• Community connects patients with resources and requirements

U.S. Healthcare Spending

• In 2022, the U.S. spent $4,464.6 billion on healthcare
• Hospital care accounted for 30.4% ($1,355.0 billion)
• Physician services made up 14.5% ($647.7 billion)
• Other personal health care was 16.5% ($734.9 billion)
• Prescription drugs accounted for 9.1% ($405.9 billion)
• Net cost of health insurance was 6.3% ($279.4 billion)
• Investment was 4.9% ($217.8 billion)
• Nursing care facilities were 4.3% ($191.3 billion)
• Government public health activities accounted for 4.7% ($208.4 billion)
• Home health care was 3.0% ($132.9 billion)
• Government administration was 1.2% ($54.2 billion)

Healthcare Costs

• The U.S. spends $4.9 trillion yearly, which is 17.6% of the GDP, equating to $14,570 per person per year in 2023
• Medicare spending was $848.2 billion in 2023
• Medicaid spending was $871.7 billion in 2023
• Developed countries spend about half as much per person and 10-11% of GDP yearly
• The bill for healthcare is paid for via insurance coverage and out-of-pocket expenses like deductibles, copays, and coinsurance

COVID impact on spending

• COVID effects in 2020 showed a 36% increase in federal government spending and a 10.3% increase in overall U.S. healthcare spending
• After COVID effects in 2021, there was a -3.5% change in federal government spending and a +2.7% change in overall U.S. healthcare spending

Important Insurance Terms

• Cap is the limit on the total insurance payout for a service per year/benefit period/lifetime
• Copayment is a fixed amount the insured pays for a covered service
• Coinsurance is the percentage of charges the insured pays after the deductible
• Covered services are those for which health insurance provides payment or coverage
• Customary, prevailing, and reasonable standards determine the amount paid to the provider of services
• Deductible is the amount an individual/family pays before insurance coverage begins
• Eligible individuals must meet certain criteria to enroll in a health insurance plan
• Medical loss ratio is the proportion of premiums spent on health services by insurers
• Out-of-pocket expenses are healthcare costs not covered by insurance
• Portability is the ability to continue employer-based health insurance after leaving a job
• Premium is the price paid for the insurance policy monthly or yearly

Government-Supported Health Insurance

• Medicare is a federal program started in 1965
• It is funded by a payroll tax of 1.45% from employees and employers
• Medicare covers those 65 and older, disabled individuals, and those with end-stage renal disease
• Enrollment period is 3 months before turning 65 and 3 months after
• 65.7 million enrolled
• Providers are paid on a fee-for-service basis
• Drugs are partially covered by Part D
• Preventative services have been expanded
• Skilled nursing or rehab care is covered but not nursing home or custodial care
• Hearing aids and eyeglasses are not covered by Medicare
• Medicare has four parts: A, B, C, and D
• Part A covers hospital care, skilled nursing, home health, and hospice care, requiring an annual deductible but no premium
• Part B is a voluntary supplemental insurance covering diagnostic and therapeutic services
• It is 25% funded by a monthly premium, with 20% copayments for most services
• Medigap policies, offered by private companies, cover the 20% copayment
• The deductible is $257 for 2025, based on yearly income
• Part C is Medicare Advantage, which is provided by private companies approved by Medicare
• Part A, B, and D are included in plans with extra benefits like vision, dental, and hearing
• Medical providers that are in the plan's network should be used
• Part D covers prescriptions
• Enrollment in parts A and B is required
• Monthly premium and annual deductible are also required
• Most Medicare have a coverage gap donut hold, the limit will be eliminated by 1/1/25, there is now a out of pocket limit of $2000 for rx drugs
• Medicaid is a federal and state program for specific categories or low-income individuals
• It is the largest federal health insurance system, with 72 million enrolled as of Oct 2024
• All states are required to provide benefits for the disabled, children, and pregnant women based on the federal poverty level
• It does not provide health care directly
• Cost is $584.4 billion (2024)
• The Medicaid Basic Health Program is optional
• States can provide coverage to citizens, aged under 64, who don’t qualify for Medicaid or CHIP with incomes up to 185% of the FPL
• The Federal Poverty Level for a family of 4 is ~$32,150 (2025)
• The Child Health Insurance Program (CHIP) had 9.6 children enrolled in 2018
• It is managed by individual states
• It provides free health coverage for pregnant women and children who do not have insurance and do not qualify for TennCare
• CoverKids is the name of TN's program
• They must be under 19 years of age
• They must be Tennessee residents
• Cannot be eligible for TennCare
• Must be U.S. citizens or qualified non-citizens
• Their household income must be at or below 250% of FPL
• Medicaid covers mandatory services like hospital and provider care, labs and X-ray, home health for adults, and nursing facility services
• Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit for children up to age 21 is required
• All states cover prescription drugs
• Many states cover dental care, vision, hearing aids, and personal care for frail seniors and people with disabilities
• Big issues regarding Medicaid Access are reimbursement rates to clinicians being comparatively low and as such many clinicians choose not to participate

Employment Based Health Insurance

• Health Insurance is the largest single category of insurance coverage in the US
• It started during WWII when employers couldn't raise wages, so they offered healthcare benefits
• Grew in the 50s and 60s based on community rating, the cost of insurance was the same regardless of the health status of a group
• Community rating was replaced by experience rating, employers and employees pay based on their groups' use of services in previous years
• Payments to clinicians and hospitals until the 90s, based on fee-for-service payments, were accused of increasing healthcare costs due to overuse
• Health Maintenance Organizations (HMOs) were introduced in 1973 as an alternative to employment-based insurance
• There is a monthly fee to cover a comprehensive package of services
• Clinicians/organizations are paid based on the number of individuals in their practice, based on capitation
• Capitation is a fixed amount of dollars a month to provide services to an enrolled member regardless of the number of services provided
• This has potential for underuse of services to save costs
• In the 90s Fee-for-service systems were replaced by Preferred Provider Organizations (PPOs)
• The Work is with only a limited number of clinicians
• Providers join the network and agree to a set of conditions that include reduced payments
• If patients use out of network providers, they pay additional costs