HLTH 301.docx

**Healthcare in the US** - Medicare-federal program, free or discounted healthcare insurance for individuals over 65 - Medicaid, free or discounted healthcare insurance for poor or low income families System is everyone who works for the company, also the organizations, ERs, clinics,...

**Healthcare in the US** - Medicare-federal program, free or discounted healthcare insurance for individuals over 65 - Medicaid, free or discounted healthcare insurance for poor or low income families System is everyone who works for the company, also the organizations, ERs, clinics, etc., also the Financing, also regulations and policies, and structure/governance. The healthcare system is influenced by culture and economy, as well as the political system. Major stakeholders in the US healthcare system: The public, employees, providers, HC facilities, government. For example; Big Pharma would lobby for a free market and higher drug prices, while we would lobby for lower prices **We spend so much money on healthcare, and our outcome is not as good as other countries** **Why is healthcare so important?** -it is important to everyone -1 in 10 people work in healthcare \- businesses that provide insurance to employees, they care about the prices -productivity which impacts economy (workers to provide money for the country) **Key indicators for comparing health system performance** **-IMR : \# of infant death before year 1/1000** How many babies die before they turn 1 out of 1000 babies that were born alive. Things mother should do during pregnancy -Folic Acid intake -Nutrition/Diet -Ultrasound Vast Disparities -**Where your born (location), by your race and income, impacts your chance of surviving your first year** What are the main issues with the healthcare system? -No central governing agency and little integration and coordination. -Delivery of health care under imperfect market conditions -No equal access -Different healthcare and insurance providers have different costs so prioritizing admin not clinical physicians **We focus on intervention not prevention** **Institute of Medicine new vision of good care** **-Do no harm, help patients** **-Make sure whatever treatment we give patients, that they work** **-Patient centered, the customer** **-Receive care in a timely manner** **-Not be wasting money** **-Have to be fair** **TRIPLE AIM** **We want to improve the health of our population, as well as the experience of the care, while also controlling costs.** **Monday, September 16th** **Class 2:** - **Health is about your physical, psychological, and social wellbeing** - **Disease progression** - **Primary Prevention** - **At risk, i.e. genetics, lifestyle (weight, diet etc)** - **Trying to prevent before disease even begins** - **Secondary Prevention** - **Early stage of the disease, already diagnosed, but under control** - **Main goal is to detect it as early as possible** - **Tertiary Prevention** - **Where disease has progressed, most expensive** - **Limit disability from disease, prevent complications or death** - **Rise of consumerism** - **Digital health and telehealth** - **Movement towards evidence based practice** The Five A's of Access ====================== - **Availability, (supply of clinicians, healthcare facilities)** - **Affordability, ability to pay for the services-Insurance** - **Accessibility, location-distance, transportation** - **Accommodation, After hours, timely, telehealth, long waits** - **Acceptability, language, religion, gender,** **Equity: Equity refers to the fairness of the healthcare system**\ **regardless of religion, race, sexual orientation and gender (Acheson,**\ **1998).**\ ** Equal access for individuals with equal need.**\ ** Equal utilization for individuals with equal need.**\ ** Equal outcomes for individuals with equal need** Who are the uninsured? - Mostly part-timers - Non Citizens - Low income households - Young Adults over ppl with Medicare **Death Spiral** Insurance is expensive, younger healthier people leave the pool, insurance company makes things more expensive, more people leaving then people coming in **Obama Care or Affordable care** Obama said a lot of ppl without insurance, and its expensive for ppl getting it without their employer -Individual mandate (He said everyone is required to have insurance) -Younger than 26, you can stay on your parents plan until you are 26 -Insurance companies cannot deny coverage or insurance because of preexisting condition -If you make less than (between 133% and %400) 400% of the federal poverty line, tax credits, subsidy -Adjusted Community Rating -If you are a company that has more than 50 employees, you have to provide health insurance for When there is a policy, lobbyists lobby for their clients or company If an Adult makes less than 130% of the federal poverty line they should qualify for Medicaid If you make 130%-400%, they will give you tax credits, subsidies you The AMA or the American Medical Association - Lobbying malpractice insurance reform Insurance Companies - Lobby for charging more, against universal coverage - Obama said public option, if insurance is too expensive for people, government insurance but Insurance companies lobbied it, and it was gone Labor Unions - Lobby for what is best for the labor force Pharma Companies - Lobby for government not being able to negotiate drug prices, when you have health insurance, they will say they will offer the drug for \$30, no government intervention or interference. Public Health - Lobby for training, enough masks, pandemic prevention. - For the people, at the state level Trend 1: Aging Population - By 2050, 21% of the population will be 65+ - Less younger people to work and more older people Trend 2: Increasing ethnic and cultural diversity - By 2050, Hispanic population will go from 16% to 30% Trend 3: Lack of Healthy Behaviors - Obesity rates increasing Trend 4: Healthcare Workers Shortage - The U.S. will face a shortfall of up\ to 124,000 physicians by 2034, impacting patient care in\ critical areas like primary care, emergency medicine, and\ psychiatry Overall, more people getting sick, less people being physicians **Healthcare Financing** **How you pay for healthcare** **-Health insurance companies pay for our services** **-** **Laws to fight fraud** **-Federal False Claims Act** - **False claims charging the government for services that were never provided** - **Anti- Kickback Statute: Yacoub has a lab, and mona is a physician, he will fly her out and show her, and if she refers her patients to him, she will get a portion of the profits** - **Physician self referral law: If a physician owns a lab or her husband and she refers her patients to them** **Health Insurance** **-Insurance is a mechanism for protection agaisnt huge financial loss** **There has to be enough interest in insuring the risk by a lot of people** **You need to be able to determine the risk of the loss, so it happens enough, be able to calculate the amount of loss, and it has to be accidental** **Health insurance is different because it covers routine care and emergencies unlike other insurances.** **Underwriting-Quiz 1** **The way they evaluate and classify your risk** - **Experience Rating: Based on previous loss (if you have an accident, your premium goes up ) (Affordable care act says for individuals getting their own insurance, you cant upcharge )** - **Community Rating: Based on location, they charge a fixed amount for everyone** - **In healthcare, we have adjusted community rating which says you can charge people based on Age, not for Sex, if someone smokes and location** **Cost Sharing Mechanisms & Health Insurance-Quiz 1** **Premium: The amount you pay monthly or annually to ensure you are covered** **Deductibles: Amount of money you have to pay out of your pocket, before your insurance company pays for your healthcare services. For Hospital stays, surgeries, and Diagnostics** **Copayment: Flat payment you have to pay for your provider. For physicans, therapist, etc** **Co-Insurance: Fixed percentage you have to pay vs the insurer (After deductible)** **Stop-loss provision: Maximum you pay before insurance steps in and covers everything** **The purpose of this is Moral Hazard, when people overutilize a service because it is fully covered. Overutilization** **She pays \$2000 for deductible.** **First country to offer universal healthcare?** **Germany** **First Emergence of Health insurance** - **The Baylor Plan- 1929** - **The Blue Cross --Hospital insurance (Blue sheild, physician)** - **Teachers who couldn\'t afford healthcare, so Baylor hospital said if you pay us \$6 a year, well cover you for 20 days** - **Insurance Transformed healthcare** **Employer Based insurance** - **Employer Mandate** - **Large companies with 50 or more have to offer health insurance for their employees** - **Experience Rating** - **Small businesses with up to 50 (FTE)** - **Tax credit** - **Community ratings** - **Small business health options program** **Self Insurance** - **Many big employers like BMC, self insure instead of paying an insurance premium at a company** - **Companies put money aside so that if employees get sick, they cover them** - **They ultimately save money, because the costs for the premium is more** **Individual non-group** - **This includes any group of people that aren\'t employed** - **Uber, Construction owner, etc** **Affordable Care Act -Exam** - **Individual Mandate: everyone needs to have insurance or pay penalty** - **\65 years old, 10 years working, if not, you pay a premium 2. \