6 J. Pearson - POD 3205 Lecture 1.pdf

A Distinctive System of Health Care Delivery I Presenter: Joshua Pearson, EdD, MHA, CPHQ, CHFP PRESENTER BIO Joshua Pearson, EdD, MHA, CPHQ, CHFP Assistant Professor, Department of Public Health [email protected] I curre...

A Distinctive System of Health Care Delivery I Presenter: Joshua Pearson, EdD, MHA, CPHQ, CHFP PRESENTER BIO Joshua Pearson, EdD, MHA, CPHQ, CHFP Assistant Professor, Department of Public Health [email protected] I currently teach in the Master of Healthcare Administration (MHA) program at DMU. I obtained my Doctor of Education in Health Professions from A.T. Still University. I am also a Certified Professional in Healthcare Quality (CPHQ) through the National Association for Healthcare Quality and a Certified Healthcare Financial Professional (CHFP) with the Healthcare Financial Management Association. I’ve been teaching for just over six years at the undergraduate and graduate level for several institutions in Missouri and Iowa. 2 Learning outcomes covered in this lecture Identify the basic characteristics of the US healthcare system. Recognize key historical developments that have shaped the nature of the delivery of healthcare. 3 Lecture overview Overview of historical milestones shaping healthcare delivery History of funding models Growth and expansion of hospitals HITECH and the growth of HIT Characteristics of today’s health care system General structure Care delivery systems Health care delivery organizations Main characteristics 4 History of Funding Models 5 Funding Model Timeline Continued HMO growth Expanded plan options – HMO Act introduces MC New provisions to Medicare; creation of expanding access to Early model HMO Social Security PPO plans coverage. Amendments of 1965- Medicare/Medicaid 1910s-1940s 1940s-1970s 1970s-Pre-ACA Post-ACA Early Blue Cross “Boom” of managed care Creation of health and Blue Shield McCarran-Ferguson Act – in response to rising insurance exchanges. regulation of insurance costs. Utilization New models developed companies devolved to management introduced. (AAPMs). Increased the states emphasis on value- based care. Kongstvedt, P.R. (2020). Health insurance and managed care: What they are and how they work (5th ed.) Jones & Bartlett 6  Blue Cross and Blue Shield Blue Cross began in 1929; Blue Shield followed. Blue Cross focused on inpatient care; Blue Shield focused on medical care with a network of providers. Started out as prepaid health benefit plans, not insurance. Enter the 1970s - the plans shift away from hospital/physician ownership and become non-profit entities (in recent decades, many plans have become for- profit and publicly owned) Kongstvedt, P.R. (2020). Health insurance and managed care: What they are and how they work (5th ed.) Jones & Bartlett 7 1945 – McCarran-Ferguson Act Prohibited federal regulation of insurance companies. Regulation of health insurance was devolved to the states. This resulted in wide variation in oversight between states. The act also provided antitrust immunity for certain activities, such as pooling of claims data for underwriting purposes Something the ACA addressed in the future. Kongstvedt, P.R. (2020). Health insurance and managed care: What they are and how they work (5th ed.) Jones & Bartlett 8 Social Security Amendments of 1965 Resulted in the creation of Medicare and Medicaid. Further pushed the trend of health care costs being paid for by third-party payers. With costs being paid by third-party payers, our system experienced a long period of cost inflation. Kongstvedt, P.R. (2020). Health insurance and managed care: What they are and how they work (5th ed.) Jones & Bartlett 9 1970s-1980s – Managed Care Managed care is introduced to help combat cost inflation. Significant changes: The HMO Act – Medicare beneficiaries can elect to enroll with HMO plans Self-funded health benefit plans (employer-based plans) Preferred Provider Organizations (PPOs) Utilization management Kongstvedt, P.R. (2020). Health insurance and managed care: What they are and how they work (5th ed.) Jones & Bartlett 10 Continued growth in managed care… The need for (and acceptance of) managed care has been contested over time, and remains a relatively controversial subject today: In the earlier years of managed care, some employers pushed employees towards lower-cost managed care plans, which resulted in additional cost- containment forces (e.g. requiring referrals from PCPs; limited provider networks). Managed care led to increased rates of claim denials Even with these challenges, managed care has continued to expand – following the Medicare Modernization Act in the early 2000s, many Medicare and Medicaid patients found themselves in some form of managed care program. 11 Affordable Care Act ACA brings about sweeping change across the entire system, with emphasis on health insurance and access to coverage. Medicaid expansion Guaranteed issue for health insurance Health insurance exchanges Individual mandate 12 ACA leads to further model redesign In addition to addressing issues with health insurance and access to care, the ACA also ushered in a greater emphasis on value-based care. ACA authorized the creation of Accountable Care Organizations (ACOs), one of the more common models for value-based care and shared-risk. New requirements for tax-exempt hospitals to develop Community Health Needs Assessments (CHNAs) to better support the health and well-being of communities. 13 System Growth – Expansion of Hospitals 14 Early 19 th Century Hospitals as we know today did not exist Almshouses to care for the poor. Pesthouses used to prevent spread of disease. Hospitals were established in the 1700s Wealthy people often received care at home – poor conditions and unskilled providers. Thus, early hospitals were primarily used by the poor. Cell from a pest house in New England (1800s) Niles, N.J. (2014). Basics of the U.S. health care system (2nd ed.) Jones & Bartlett Image source: https://www.hjnews.com/montpelier/pest-houses---a-necessary-but-inhumane-practice/article_a6e918db-e873-57be-8e3b-85cf5db389e5.html 15 Early 20 th Century Significant changes occur which resulted in hospital growth: Standardized medical education Establishment of the AMA Shift of ownership from physician-owned to church- related and government- operated. Hospitals become generally accepted across all socioeconomic classes. Niles, N.J. (2014). Basics of the U.S. health care system (2nd ed.) Jones & Bartlett Image source: https://www.nursing.upenn.edu/nhhc/nurses-institutions-caring/history-of-hospitals/ 16 Additional Milestones Many hospitals began offering outpatient services by the 1980s Hospitalists emerged as a profession. Accreditation and regulation expand and improve quality of care. Growth of third-party insurers results in inflationary revenue for hospitals. Niles, N.J. (2014). Basics of the U.S. health care system (2nd ed.) Jones & Bartlett 17 HITECH and the Growth of HIT 18 HITECH Act The Health Information Technology for Economic and Clinical Health Act (HITECH) was enacted in 2009. Although this act addressed several issues, HITECH is largely recognized for the widespread adoption of EHRs. HITECH developed an incentive program called “Meaningful Use”, which offered incentives for meeting specific criteria. Burde, H. (2011). The HITECH Act: An overview. https://journalofethics.ama-assn.org/article/hitech-act-overview/2011-03 19 HITECH Act Percentages of hospitals that adopted at least a basic electronic health record system, 2008-2015. Adler-Milstein, J., & Jha, A.K. (2017). HITECH Act drove large gains in hospital electronic health record adoption. Health Affairs, 36(8). https://doi.org/10.1377/hlthaff.2016.1651 20 Beyond Meaningful Use Meaningful Use program eventually phased out and led to more advanced requirements for HIT: Promoting interoperability programs for hospitals Health information exchanges (HIEs) to support quality of care. Office of the National Coordinator (n.d.). Promoting Interoperability. https://www.healthit.gov/topic/meaningful-use-and-macra/promoting-interoperability 21 Characteristics of the US Healthcare System 22 General Funding Structure The US health care system can be described as a mixed public/private model from an insurance coverage perspective. According to 2020 Census data on health insurance coverage: 8.6% of people did not have any insurance coverage compared to 91.4% with coverage. Of those with coverage: 66.5% of people had private health insurance coverage 34.8% of people had public health insurance coverage United States Census Bureau (2021). Health insurance coverage in the United States: 2020. https://www.census.gov/library/publications/2021/demo/p60-274.html 23 Government Responsibilities To support the US health care system, the federal government has several responsibilities including: Setting legislation for national strategies Administering the Medicare program Setting basic requirements for the Medicaid program Regulating pharmaceutical products Running federal marketplaces Providing premium subsidies/support for marketplace coverage. The Commonwealth Fund (2020). International health system profiles: United States. https://www.commonwealthfund.org/international-health-policy-center/countries/united-states 24  Organization US system is frequently referred to as a mixed public/private model Public aspect of model is governed and/or administrated by federal and/or state governments. Private includes everything outside of that. 25 Current Care Delivery Systems While our health system is complex and could be categorized in a variety of different ways, the system is generally grouped into three large pools: Preventive Care Acute Care Long-Term Care Emergency Care Primary Prevention Services Urgent Care Activities of Daily Living Secondary Prevention Services Prehospital care (e.g. primary, Palliative Care Tertiary Prevention Services specialty, chronic care) Knickman, J.R., & Kovner, A.R. (Eds) (2015). Health care delivery in the United States (11th ed.) Springer Publishing Company. 26 Health Care Delivery Organizations A variety of different stakeholders play a role in supporting our health care system. Solo Practices Community Hospitals Assisted Living Facilities Rehabilitation Hospitals Single Specialty Groups Physician Organizations Psychiatric Hospitals Multispecialty Groups Community Health Centers Urgent Care Centers Ambulatory Surgery Centers Long-term Care Centers Knickman, J.R., & Kovner, A.R. (Eds) (2015). Health care delivery in the United States (11th ed.) Springer Publishing Company. 27 Main Characteristics of the System Minimal integration and coordination of care between stakeholders. High-cost system with lower-quality outcomes. Imperfect conditions affect patient engagement. Enterprise of risk influences system behavior. Inequities related to access to care and treatment outcomes. Great emphasis placed on innovation via technology and system redesign with limited regulation on cost containment. 28 Looking ahead to the next lecture… The next lecture in this series will focus on basic models for measuring health status and the quality of health care services. While our health system costs more than any other country’s system, outcomes tend to trail behind on an international scale. This, among other pressures on our health system, has ushered in system redesign focused on value-based care. As our system embarks on this transformation, the characteristics of our system will mold and adapt to reflect a more integrated model. 29 Questions? Feel free to reach out! Thank you! Dr. Joshua Pearson, EdD, MHA, CPHQ, CHFP [email protected] References Adler-Milstein, J., & Jha, A.K. (2017). HITECH Act drove large gains in hospital electronic health record adoption. Health Affairs, 36(8). https://doi.org/10.1377/hlthaff.2016.1651 Burde, H. (2011). The HITECH Act: An overview. https://journalofethics.ama-assn.org/article/hitech-act-overview/2011-03 The Commonwealth Fund (2020). International health system profiles: United States. https://www.commonwealthfund.org/international-health-policy-center/countries/united-states Kongstvedt, P.R. (2020). Health insurance and managed care: What they are and how they work (5th ed.) Jones & Bartlett Knickman, J.R., & Kovner, A.R. (Eds) (2015). Health care delivery in the United States (11th ed.) Springer Publishing Company. Niles, N.J. (2014). Basics of the U.S. health care system (2nd ed.) Jones & Bartlett Office of the National Coordinator (n.d.). Promoting Interoperability. https://www.healthit.gov/topic/meaningful-use-and- macra/promoting-interoperability United States Census Bureau (2021). Health insurance coverage in the United States: 2020. https://www.census.gov/library/publications/2021/demo/p60-274.html 31