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221 Cards in this Set
- Front
- Back
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Federal and state policy and law shape virtually all aspects of the
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healthcare system, from structure and organization, to service delivery, financing, and administrative and judicial oversight
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Policies affect directly or indirectly all aspects of
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daily life, actions, behaviors, and decisions
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Governments use public policies to intervene when
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market fails to be efficient (to correct market failures), and for political, moral, ethical, or economic reasons
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Not to take action is also a
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policy decision
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Policy and law have long played a role in everyday
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public health activities as well as in many historic public health accomplishments
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Health policies have a meaningful role in the protection against
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injury, disease, disability, risk mitigation, and the reduction of disparities and exclusion
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One main focus in public health is finding the appropriate balance between
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population welfare and individual freedoms
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What is policy?
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Authoritative decisions made in the legislative, executive, or judicial branches of government that are intended to direct or influence the actions, behaviors, and decisions of others
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Who makes policy?
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government (federal, state, local)
authoritative decision makers private individuals/ entities/interest groups |
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Public policy problems
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beyond individual concerns and affects the greater community
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Public policy includes
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1.) statutes, formed through legislation
2.) judicial interpretations and decisions 3.) rules and regulations 4.) standard operating procedures 5.) results of initiative and referenda elections 6.) executive orders 7.) any type of decision by those in government on behalf of themselves or the public |
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Legislative branch
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house
senate |
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Executive branch
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White House
Administrative agencies |
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Judicial branch
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courts
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How a Bill becomes law
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Representatives introduce bill in the House, bill is read in the house and assigned to a committee by the Speaker, bill leaves committee and is scheduled for floor consideration and debate and may be amended, House passes bill, Bill is sent to Senate
Senator introduces bill in the Senate, bill is read in the Senate and is assigned to a committee by the Majority Leader, bill leaves committee and is scheduled for floor consideration and debate and may be amended, Senate passes bill, and bil is sent to House A conference committee is created to resolve differences if both chambers do not pass an identical bill, identical bill is passed by both House and Senate or branch agrees to the other branch's version or bill is ammended and both branches vote again and pass ammended version, bill is presented to the President, who has four options Option 1: President signs bill into law Option 2: During congressional session, bill becomes law after 10 days without presidential signature Option 3: When not in session, bill does not become law without the presidential signature Option 4: President vetoes bill, two-thirds vote in House and Senate can override veto *Most bills do not pass through the process the first time, but are revised and re-introduced in subsequent sessions. Sometimes it takes years for a bill to pass, if at all. |
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State-level policymaking is important - similar process
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legislature instead of congress, governor instead of president
key decisions are made on state level (water quality, health policy licensure, medicaid coverage) variation among states in how policymaking process is structured State/local health bureaucracy: state level agencies (ex: Medicaid, public health) local public health agencies |
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Interest groups
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general term used to describe a variety of organizations that focus on a particular issue of issues and have the goal of influencing and educating policymakers and the general public
interest groups do not make policy but can have a strong influence on policymakers interest groups represent their members on the basis of shared attitudes and raise awareness of pubic issues mostly by promoting those policies they favor and oppose the policies they are not in favor of |
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policy typology
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redistributive
regulatory distributive |
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redistributive policy
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resources from one group are taken and redistributed to provide benefits to other groups through income, taxes or services (welfare reform, tax reform, unemployment, food and special education vouchers)
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regulatory policy
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to constrain the actions or sanction the actions of a group of interests; influences actions, behaviors, and decisions through direct approaches. (restrictions from entry to the market, price controls, quality control in the delivery of services, controls that preserve the market, social regulation)
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distributive policy
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address particular needs of an identifiable group, and the costs are shared among all taxpayers; provides direct benefits to specific groups or activities (e.g. research, national parks, highway and airport construction).
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Longest Model of the Health Policymaking Process
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Policy Formulation Phase:
Preferences of individuals, organizations, and interest groups, along with biological, cultural, demographic, ecological, economic, ethical, legal, psychological, social, and technological inputs. Agenda setting: 1.) Problems 2.) Possible solutions 3.) Political circumstances Development of Legislation Window of opportunity - opens when there is a favorable confluence of problems, possible solutions, and politcal circumstances Policy Formulation Phase and Policy Implementation Phase are bridged by Formal Enactment of Legislation Policy Implementation Phase: Rulemaking Operation = Policy, which leads to feedback feedback = Policy Modification Phase: Feedback from individuals, organizations, and interests groups experiencing the consequences of policies, combined with the assessments of the performance and impact of policies by those who formulate and implement them, influences future policy formulation and implementation, this feeds into Policy Formulation and Policy Implementation Phases |
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The policy formulation phase
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the process of defining, considering, and accepting or rejecting policy options.
it involves decisions on what, if anything, should be done about a given problem and adoption of legislation or administration rules that appropriately enact the agreed upon principles the weighing of options takes into account various factors including: 1.) who benefits (the more the better) 2.) who might be negatively affected (the fewer the better) 3.) time required to implement the solution 4.) associated cost and financing 5.) political complexities |
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agenda setting
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represents an ongoing competition among issue proponents to gain the attention of media professionals, the public, and policy elites
the agenda setting process narrows a set of conceivable subjects to the set that actually becomes the focus of attention agendas are contingent upon: 1.) competing entries 2.) ability to influence groups 3.) positions & views of key policymakers 4.) preferences of interest groups 5.) preferences of decision maker |
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Policy adoption/enactment of legislation
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adoption represents the decision that the government will address the problem through an agreed course of action
the adoption phase begins with the formulation of a policy proposal and ends, if ever, with the formal acceptance as a law, regulation, administrative directive, or other decision made according to the rules of the relevant political arena adopted policies rarely specify exactly what needs to be done; they may require additional policy decisions in other arenas |
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Policy implementation
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1.) Translates policy into action (programs, projects, interventions)
2.) Is crucial. A policy is generally useless if it isn't implemented. 3.) Transforms the legislative language into managerial and administrative action. 4.) Inadequate implementation contributes to reduce or failing the achievement of the established goals. |
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Who implements policy?
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1.) The executive branch
2.) The legislative branch through specific legislation and regulations 3.) The judicial branch 4.) Other levels of government 5.) Private actors 6.) The bureaucracy, through its agencies 7.) Courts, through the interpretation of statutes (in some countries) 8.) Community/or other organizations that were granted authority/resources to do so. |
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Policy Modification
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Monitoring provides policy-relevant knowledge about the consequences of previously adopted policies.
Monitoring helps: 1.) assess the degree of compliance 2.) discover unintended consequences of policies and programs 3.) identify implementation obstacles and constraints 4.) locate sources of responsibility for departures from policies 5.) Modification based on feedback from individuals, organizations and interest groups on the consequences of policies leading to further policy development and legislation |
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State and federal regulations affects all facets of the
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delivery and financing of healthcare services
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States regulate:
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health insurance premiums and benefits covered; health professional licensing and their scope of practice; control of communicable diseases and environmental sanitation
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Medicare regulates
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fees for hospitals and doctors as well as provides quality standards.
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ACA provides
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nationwide minimum requirements for insurance
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“No-duty-to-treat” principle
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Generally speaking, individuals have no legal right to health care services or to public health insurance and, correspondingly, there exists on the part of health care providers no general legal duty to provide care.
Exception: The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law that requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay |
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Individual Rights and Health Care: A Global Perspective
U.S. is one of the only high-income nations that does not guarantee |
health care as a fundamental right
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U.S. is the only developed nation that does not have
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a system to ensure its population access to healthcare (even with the passage of ACA)
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Some two-thirds of constitutions world-wide address
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health or health care. Having language respecting health rights in a constitution does not guarantee that the right will be recognized or enforced.
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Individual Rights and the Health Care System Categorize health care rights in 3 ways:
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1. Rights related to receiving services explicitly provided under health care, health financing, or health insurance laws.
2. Rights concerning freedom of choice and freedom from government interference when making healthcare decisions. 3. The right to be free from unlawful discrimination when accessing or receiving health care. |
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Individual Rights in a Public Health Context
One simple way to think about individual rights in a public health context is to use a balancing approach— |
what might the appropriate legal trade offs be between private rights and public health?
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Individual Rights in a Public Health Context
Police powers: |
state and local government authority to require individual conformance with established standards of conduct; standards are designed to promote and protect the public’s health, safety, and welfare, and to permit government control of personal, corporate, and other private interests
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Individual Rights in a Public Health Context
Prevailing view is that the Constitution empowers government to act |
in the name of public health but does not require it to do so.
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This interpretation refers to what is known as the“negative constitution”
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—the idea that the Constitution does not require government to provide any services, public health or otherwise.
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This approach to constitutional law derives from the
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fact that the Constitution is phrased mainly innegative terms
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Courts define health policy through its decisions on health related cases such as:
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• Jacobson v. Massachusetts – gives public health power to enforce vaccinations
• Roe v. Wade – provides women with constitutional right to obtain an abortion • Simkins v. Moses H. Cone Memorial Hospital - led to the elimination of segregated hospitals/healthcare. |
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Two prevailing theories why legislators enact laws:
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• Public Interest Theory – legislation is enacted according to what legislators believe is in the public interest.
• Economic Theory – legislators enact legislation for their own self interest. |
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Public interest view of government objectives is to
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improve efficiency and to redistribute income in a more equitable manner.
• Improve efficiency by limiting monopolies (increases competition; keeps costs low) • Improve public welfare by moderating externalities or side effects of industry (pollution, public safety) • Redistributes wealth for the public good (Medicare, Medicaid) |
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Primary goal of legislators is to
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get re-elected and their legislative action is to garner support from voters and interest groups.
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Two major groups that impact legislation:
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• Population groups – major organized groups such as AARP, NRA, Tea Party.
• Industry groups – AMA, Pharma, Gas/Oil companies |
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Health Policy Objectives of the 2 Theories of Government
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1.) Public Interest Theory:
Redistribution: Assist those with low incomes Improve Efficiency: Prevent monopoly abuses and protect environment 2.) Economic Theory: Redistribution: Provides benefits to those able to deliver political and financial support Improve Efficiency: Efficiency objective unimportant –protects industry and provides them with redistributive benefits |
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The Affordable Care Act is a good example
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of both of these views in action:
• Public Interest View – makes healthcare insurance more accessible; decreases barriers; increases individuals right to healthcare. • Economic View – winners are the healthcareindustry, especially insurance companies |
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Economists believe that people are
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rational actors who will never purposely choose to make themselves worse off
• People seek to maximize utility Given the scarcity of resources, decisions need to be made about the production, distribution, and consumption of health care resources • Consider individual preference and efficiency |
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Demand:
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the quantity of goods and services that a consumer is willing and able to purchase over a specified time
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Common demand shifters
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• Income
• Quality (actual or perceived) • Price of the original good, price of a substitute good, and price of a complementary good |
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Demand elasticity
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is the percentage change in the quantity demanded resulting from a 1% change in price or income.
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If a product is elastic
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a change in price/income will result in an equivalent or greater change in demand.
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If a product is inelastic
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demand for the good is not sensitive to a change in price/income.
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Health insurance acts as a buffer between the
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consumer and cost of health care goods and services
• Goods and services cost the consumer less than the charged price because of the presence of health insurance Moral Hazard • Because a consumer does not pay the full cost of a good,the consumer may purchase more than goods than he would otherwise purchase without insurance |
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Supply
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is the amount of goods and services that producers are able and willing to sell at a given price over a given period of time.
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Common supply shifters
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• Input costs
• Sale price • Number of sellers • Change in technology |
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Suppliers are driven to maximize
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profit.
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In a competitive market, profit is maximized at the level of output where
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marginal cost equals price.
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Equilibrium exists in the market when there is a balance between
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the quantity supplied and the quantity demanded.
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Supply elasticity
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is the percentage change in quantity supplied resulting from a 1% increase in the price (or other variables, such as inputs) of buying the good
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If a product is elastic
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a change in price (or other variables) will result in an equivalent or greater change in supply.
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If a product is inelastic
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supply of the good is not sensitive to a change in price (or other variables).
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The presence of health insurance may impact a provider’s
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willingness to supply goods and services
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Health Insurance and Supply Competing concerns |
• Providers act as patient’s agent and act in patient’s best interest
• Providers may have a financial incentive to act or refrain from acting in a certain way due to insurance arrangements or the lack of insurance. |
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Supplier-induced demand
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is the provider version of moral hazard
• Providers create a demand beyond the amount the well informed consumer would have chosen. |
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Market structures:
Perfectly competitive market |
efficiently allocate resources
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Monopolies
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Single seller controls market
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Oligopolies
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Few dominant firms, substantial barriers to entry
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Monopsonies
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Few consumers who control price paid to sellers
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Health care is a
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monopolistically competitive market
• Few dominant firms with significant market power and many smaller firms without market power |
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A typical market transaction involves two parties
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• Consumer and supplier
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Health care transaction with an insured patient involves three parties
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• Consumer (patient)
• Supplier (provider) • Insurers |
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Presence of third party (insurers) changes consumer and supplier analysis of costs and benefits of each transaction –
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consumers are less likely to consider costs in their decision making process
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A market failure means that
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resources are not produced or allocated efficiently
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Common reasons for market failures
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• Concentration of market power
• Imperfect information • Consumption of public goods (goods that are available to everyone) • Presence of externalities (the cost or benefit that affects a party who did not choose to incur that cost or benefit) |
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Ways to address market failure
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• Do nothing
• Gov’t finances or directly provides public goods • Gov’t increases taxes, tax deductions, subsidies • Gov’t issues regulatory mandates • Gov’t prohibitions of certain goods or services • Redistribution of income (Medicare and Medicaid) |
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major public health insurance programs in the United States
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• Medicaid
• Children’s Health Insurance Program • Medicare |
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Beneficiary
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• Consumer, individual who is covered by the plan
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Premium
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An annual fee paid by the beneficiary to the health plan, usually in monthly installments, to secure health insurance coverage
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Deductible
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An amount of money a beneficiary must pay out-of-pocket before the insurance company assists with paying for services.
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Cost-sharing
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Co-payment or co-insurance, an amount the beneficiary pays per service after the deductible is met
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People choose to be insured because of uncertainty and risk
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• There is uncertainty whether an expensive and unforeseen event that impacts their health status will occur
• There is risk of financial exposure due to the unexpected event |
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Insurance companies are concerned about
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uncertainty and risk because they are businesses that need to cover the cost of their expenditures
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Uncertainty and risk may lead to
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adverse selection
Unhealthy people over-select a particular plan, making the plan more expensive |
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Insurance companies set premiums to cover
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most of their expenses
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Experience rating
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• Based on health status and claims in prior year(s)
• Also referred to as medical underwriting |
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Community rating
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• Based on factors unrelated to previous use of medical care, such as geography or age
• All persons in the community rating system pay the same amount |
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Health Insurance Portability and Accountability Act of 1996 (HIPAA)
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• HIPAA-covered group plans may not exclude or limit otherwise qualified individuals due to pre-existing conditions
• HIPAA-covered group plans may not charge different premiums based on identified health factors to similarly situated individuals • State laws on medical underwriting vary |
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Managed care integrates the
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provision and payment of health care services.
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Ideally, managed care contains
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costs while providing necessary and high quality health care services
Some fear that managed care companies provide fewer services than necessary or lower quality services to save money |
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Health Maintenance Organization (HMO)
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• Pays providers a salary or capitation
• Beneficiaries may only use in-network providers • HMO coordinates and controls receipt of services |
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Preferred Provider Organization (PPO)
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• Pays provider on a discounted fee schedule
• Beneficiary may use in- or out-of-network providers |
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Point of Service Plans (POS)
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Combines features of HMO and PPO
• Pays providers with capitation or other risk sharing arrangement • Has a provider network; beneficiaries may use out-of-network provider for designated services • Has a gatekeeper to control and coordinate care |
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Managed Care – Cost Containment Tools
Performance-based salary bonuses and withholds |
• Provider receives a salary as a managed care organization employee
• Salary is subject to bonuses or withholds |
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Discounted fee schedule
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• Provider accepts less than fee-for-service rates to participate in managed care network
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Capitated payment
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Provider receives a per member/per month payment for all services rendered within scope of practice
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Gatekeeper
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Managed care organization uses a primary care provider to make sure only necessary and appropriate care is provided
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Utilization review
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Managed care organization reviews and approves or denies services requested by provider
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Case management
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Managed care organization manages and coordinates patient care
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Medicaid
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A federal-state public health insurance program for the indigent.
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Medicaid
Program administration |
• Federal: Center for Medicare and Medicaid Services (CMS) outlines mandatory and optional populations and benefits covered under Medicaid
• State: state Medicaid agencies run programs, select which optional populations and benefits to cover in the state program |
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All states participate in
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Medicaid
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Medicaid generally covers the following low-income categories:
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• Pregnant women (185% of FPL)
• Children (133% of FPL) • Adults in families with dependent children (19%of FPL) • Individuals with disabilities • Elderly |
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Medicaid
Must meet 5 eligibility requirements: |
Categorical,
Income level, Resources, Residency and Immigration status |
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Medicaid covers
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extensive in-patient, outpatient and long-term care benefits
• Some benefits are mandatory, others are optional • Covers most physician visits, labs and x-rays • Family planning • Early and Periodic Screening Diagnostic and Testing services are a comprehensive set of mandatory services for children • Nursing home care • Home health services |
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Medicaid Enrollees and Expenditures by Enrollment Group, 2007
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Enrollees = Total = 58 million: Disabled: 15% Adults: 25% Children: 49% Expenditures on benefits = Total = $300 million: Elderly: 25% Disabled: 42% Adults: 12% Children: 20% |
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Medicaid is jointly financed by the |
federal and state governments
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Medicaid — Financing
Matching system |
• Federal Medical Assistance Percentage determines the matching rate; rate is tied to each state’s per capita income with poorer states receive a higher federal match, and must be at least 50/50
Beneficiary cost-sharing: • very limited cost-sharing allowed |
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Medicaid
Reimbursement levels vary by |
States and have a lot of discretion in setting rates |
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Medicaid |
state-determined fee schedule
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Managed care providers paid according to
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contracts between the state and the managed care organization
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Medicaid reimbursement is typically much lower
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than private insurance or Medicare reimbursement
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Medicaid
States may apply to the federal government for |
waivers of Medicaid requirements
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Medicaid Section 1115 waivers |
• Secretary of Health and Human Services may grant a section 1115 waiver to allow for a research and demonstration project that “assists in promoting the objectives” of Medicaid
• Use states as “policy laboratories” to test health reform ideas • Health Insurance Flexibility and Accountability Act |
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Florida has a Medicaid Waiver for their Medicaid Reform initiative that began in
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2008
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All non-Medicare eligible adults under
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65 with incomes up to 133% of poverty will be eligible in if the state agrees to it
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Medicaid
Also, must cover all children |
6–19 at 133% of poverty
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Medicaid
Immigrants still have |
5 year ban but states have option to cover legal immigrant pregnant women and children who have been in the country > than 5 years
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Medicaid
Federal government pays |
100% of newly eligible Medicaid expansion for two years then phases down to covering 90% by 2020
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Medicaid
Florida did not agree to |
expand Medicaid – 25 other states have
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Children’s Health Insurance Program (CHIP)
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A block grant program designed to provide health insurance to low-income children whose family income is above the Medicaid eligibility level in their state
Reauthorized in 2009 and extended in the ACA; Authorization through 2019, funding through 2015 |
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All states participate in
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CHIP
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Three options for CHIP structures
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Incorporate CHIP into Medicaid program as an expansion population
• Create separate CHIP program • Hybrid program: Some CHIP children are in Medicaid and some are in a separate CHIP program • All three types of options are used by the states |
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CHIP — Financing & Eligibility
Federal-state matching program |
• “Enhanced” match — CHIP match will always be higher than the state’s Medicaid match
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CHIP — Financing & Eligibility
States may cover children up to |
300% Federal Poverty Level (FPL)
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Children who are eligible for Medicaid
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must be enrolled in Medicaid, not CHIP
States may impose waiting periods, enrollment caps, and other measures to limit expenses |
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Medicare
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• A federally-funded health insurance program for the elderly and some persons with disabilities.
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Medicare is administered by
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CMS
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Medicare covers two main populations
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– elderly and disabled
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Medicare
Elderly requirements |
• At least 65 years old
• Eligible for Social Security by having worked and contributed to Social Security for at least 10 years |
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Medicare
Disabled requirements |
• Individual is totally and permanently disabled and has received Social Security Disability Insurance for at least 24 months OR
• Has End Stage Renal disease |
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Medicare — Benefits
Medicare split into 4 parts, each with its own set of benefits: |
• Part A: Hospital Insurance - Inpatient hospital, skilled nursing facility, hospice
• Part B: Supplemental Medical Insurance - Physician services, outpatient services, limited preventive services • Part C: Managed Care - Same services (sometimes receive additional services) delivered through a managed care arrangement; Part C includes other types of plans as well • Part D: Prescription Drug Coverage - May receive through private drug plans or managed care arrangement |
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Medicare — Benefits
Part A: |
Hospital Insurance - Inpatient hospital, skilled nursing facility, hospice
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Medicare — Benefits
Part B: |
Supplemental Medical Insurance - Physician services,outpatient services, limited preventive services
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Medicare — Benefits
Part C: |
Managed Care - Same services (sometimes receive additional services) delivered through a managed care arrangement; Part C includes other types of plans as well
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Medicare — Benefits
Part D: |
Prescription Drug Coverage - May receive through private drug plans or managed care arrangement
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Medicare –Provider Reimbursement
Physicians |
Paid on a fee-for-service basis according to a Medicare fee schedule
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Medicare – Provider Reimbursement
Hospitals |
Paid on a prospective payment system based on diagnosis
• Diagnostic Related Groups for inpatient care • Ambulatory Payment Classification for outpatient care |
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Medicare – Provider Reimbursement
Managed Care |
• Plans paid a negotiated capitated rate by the federal government
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Affordable Care Act Changes to Medicare
New coverage for preventive services without |
costsharing
Eventually closes Part D doughnut hole • Short-term relief as well Reimbursement changes for hospitals and physicians Cost changes to beneficiaries |
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There have been numerous health reform attempts in the
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U.S.
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Prior to 2010, all attempts at national health reform to create universal or near-universal coverage have
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failed
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Health Reform
Some successes at the state level |
(Mass, Oregon, Hawaii)
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Key Failed Attempts at National Health Reform
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•1912 Progressive Party candidate Teddy Roosevelt supported social insurance platform that included health insurance
•1915 American Association for Labor Legislation proposal for working class health insurance •President Truman supported national health reform upon taking office, won re-election on national health insurance platform in 1948 •President Nixon initial health reform proposal in 1969 and revised proposal in 1972 •President Clinton Health Security Act in 1993 |
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Difficulty of Reform in the U.S.
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•Individualistic culture
•Dislike of big government •Lack of consensus •Federal system rules and structure make it difficult to achieve major reform •States generally home to social welfare issues •Powerful interest groups against national health reform •Path dependency |
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Why did the Affordable Care Act pass when so many prior attempts had failed?
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•Commitment and leadership
•Learned lessons from past failures •Political pragmatism |
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Nearly 50 million uninsured in
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•2008 (16% of population)
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Uninsured becoming an
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•economic burden for the whole country and employers concerned about rising healthcare costs
Controversy: •Too much government interference in private lives? •Constitutional? |
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Key Elements of ACA
Individual Mandate |
•most Americans are required to have health insurance with “minimum essential coverage” or face a penalty.
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Key Elements of ACA
Insurance Exchanges |
•states and federal government establish marketplaces where individuals and small businesses can purchase insurance.
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Key Elements of ACA
Role and Obligation of Employers |
companies with more than 50 employees must offer health insurance to employees or face a $2,000 fine per employee.
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Key Elements of ACA
Medicaid Expansion |
•States to expand Medicaid program to include individuals up to 138% of FPL
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Key Elements of ACA
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Individual Mandate
Insurance Exchanges Role and Obligation of Employers Medicaid Expansion New Rules for Insurance Companies New approaches to healthcare delivery |
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Key Elements of ACA New Rules for Insurance Companies |
•limit the ability to deny coverage for any reason such as health status or pre-existing condition and children can be covered under parents plan through the age of 25 regardless if in college.
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Key Elements of ACA
New approaches to healthcare delivery |
•recognizes the importance of cost and quality in healthcare delivery
•Public health initiatives •Information technology advancements •Delivery systems reforms (Accountable Care Organizations, different payment models) |
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State and Federal Health Insurance Exchanges called
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•Health Insurance Marketplaces.
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Insurance Exchanges
Federal exchange found at |
Healthcare.gov
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Insurance Exchanges
Individuals can shop for |
•approved plans and check eligibility for
Medicaid and CHIP (Kidcare). |
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Must have insurance coverage by
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•March 31, 2014 of face fine when you submit tax return ($95 to up to 1% of household income).
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Insurance Exchanges
Four levels of insurance
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each has different coverage and premiums.
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ACA Premium and Cost Sharing Subsidies
Premium tax credits available for |
individuals who purchase insurance in an exchange and have income between 133%–400% of poverty
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ACA Premium and Cost Sharing Subsidies
Cost sharing subsidies available for |
•individuals who purchase insurance in an exchange and have income up to 250% of poverty
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ACA Premium and Cost Sharing Subsidies
To quality |
must be a US citizen or legal resident, not eligible for any type of public insurance, and not have access to employer-sponsored insurance
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Marketplace Health Plan Decision Tree
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Starts with:
Individual or Family Income, which branches off to 1.) 400% of FPL or above, which branches off to a.) No health issues, never go to doctor, which branches off to Choose Bronze Plan b.) Occasional health problem, short-term medication use, which branches off to Choose Silver Plan c.) Chronic health problems, long-term medication use, which branches off to Choose Gold or Platinum Plan 2.) Below 400% of FPL $11,490 - $45,960, which branches off to a.) Choose Silver Plan |
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Private Insurance Market Changes
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•No pre-existing condition exclusion
•Dependent coverage to age 26 •Preventive services without cost sharing •Prohibitions against lifetime and annual coverage limits •No rescission without fraud •New appeals process •Premium rate reviews •Guaranteed issue and renewability •Rate variation limits •Essential health benefits •Wellness plans |
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Financing Health Reform
Will cost about |
$1.3 trillion over 10 years and will be funded by:
•Changes to Medicare provider reimbursement •Changes to Medicare Advantage reimbursement •Medicare Part A increases for high earners •Changes in Medicare Part D subsidies •Changes in Medicare employer subsidy •Changes in Disproportionate Share payments to hospitals •Increase Medicaid prescription drug rebate paid by manufacturers •Income tax code changes •Health industry fees •Tax on high cost health insurance plans. Most changes is born on the backs of providers, insurers and manufacturers since they will be benefiting the most by having more people insured – creating bigger consumer pool for their products and services. |
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Legal Battles
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•Many states filed a suit to stop the implementation of the ACA (including Florida).
•Concerns over constitutionality as well as states rights being over-ridden by federal government. •Main issues were the individual mandate for everyone to have health insurance and the expansion of Medicaid. •June 2012, U.S. Supreme Court upheld the constitutionality of the law including the individual mandate but made the Medicaid expansion a state option. |
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Endless Political Posturing
Public views of ACA |
not favorable
•Still lack of awareness and confusion about the law •Lot of misinformation being spread through multi-media outlets States and various healthcare stakeholders (providers, health insurance companies, employers) are still trying to sort out implementation Constant lobbying by interest groups and legislative bills being presented to change or repeal the law. •Yet there is a civic obligation to obey the law |
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Institute of Medicine - Err is Human: Building a Safer Health System (1999)
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Tens of thousands of Americans die each year as a result of preventable mistakes in their care,the report lays out a comprehensive strategy by which government, health care providers, industry, and consumers can reduce medical errors
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Institute of Medicine -Crossing the Quality Chasm: A New Health System for the 21st Century (2001)
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Outlines 6 areas for improvement:
safety, effectiveness, patient centered care, timeliness of care, efficiency of delivery of care, equitable provision of care. |
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Although medical errors are not a new problem,
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framing the issue as a public health problem is a relatively new phenomenon.
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Overall, more people die each year from medical errors than from
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motor vehicle accidents, breast cancer, or AIDS.
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Key causes of errors affecting patient safety in hospitals:
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• Medication Errors
• Infection Control • Injuries from falls • Injuries from procedures |
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Other causes of medical errors may include:
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1. failure to complete an intended medical course of action or implementing the wrong course of action,
2. using faulty equipment or products in effectuating a course of action, 3. failing to stay abreast of one’s field of medical practice, 4. health professional inattentiveness or negligence, 5. optimal treatments for many illnesses are not yet known, and 6. the culture of medicine itself |
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Policy makers have begun shifting their attention to
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medical error reforms that are less reactive and more centered on error prevention and patient safety improvements.
The primary objective of these reforms is to redesign health care delivery methods by: More standardization of care • Improving information technology (EHRs, CPOE, CDSS) • Encouraging patients to take a more active role in their care |
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QUALITY CONTROL THROUGH LICENSING AND ACCREDITATION
Licensing of health care professionals and institutions is an important function of |
state law, as it filters out those who may not have the requisite knowledge or skills to practice medicine.
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The licensing function is used in the
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promotion of healthcare quality in only the bluntest sense. This is because the only method by which to promote quality through licensure is the granting or denial of the license.
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State licensing was designed
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not with health care quality per se in mind, but rather with an eye toward protecting the medical professions from unscrupulous or incompetent providers.
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QUALITY CONTROL THROUGH LICENSING AND ACCREDITATION
Finally, licensure plays an important role in defining |
the permissible “scope of practice” of the various types of health care providers.
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QUALITY CONTROL THROUGH LICENSING AND ACCREDITATION |
accreditation process which usually entails a detailed examination of the organizations policies, procedures and practices.
They include: Hospitals – JCAHO• Mental Health organizations - CARF• Health Departments - PHAB |
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PROMOTING HEALTH CARE QUALITY THROUGH THE STANDARD OF CARE
The professional standard of care is the |
legal standard used in medical negligence cases to determine whether health professionals and entities have adequately discharged their responsibility to provide reasonable care to their patients.
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PROMOTING HEALTH CARE QUALITY THROUGH THE STANDARD OF CARE A patient seeking to hold a health professional responsible for substandard care or treatment must demonstrate |
(1) the appropriate standard of care,
(2) a breach of that standard, (3) measurable damages, and (4) a causal link between the health professional’s breach and the patient’s injury |
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TORT LIABILITY OF HOSPITALS, INSURERS, AND MANAGED CARE ORGANIZATIONS
The general rule is that employers are not vicariously liable for the
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improper actions of independent contractors; however, courts have developed exceptions to this rule—e.g., actual agency and apparent agency—that are concerned with the scope of a relationship than with the formal characterization of the relationship.
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TORT LIABILITY OF HOSPITALS, INSURERS, AND MANAGED CARE ORGANIZATIONS
Corporate liability |
holds entities accountable for their own “institutional” acts or omissions when their negligence causes or contributes to an injury.
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TORT LIABILITY OF HOSPITALS, INSURERS, AND MANAGED CARE ORGANIZATIONS
• Several general areas give rise to litigation around entities’ direct quality of care duties to patients: |
failure to screen out incompetent providers; failure to maintain high quality practice standards; failure to take adequate action against clinicians whose practices fall below accepted standards; and failure to maintain proper equipment and supplies
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MEDICARE INCENTIVIZING HEALTH CARE QUALITY
As the single largest payer in the U.S. health system
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Medicare is a major national driver of health policy and payment reforms
How the Medicare program addresses issues pertaining to quality is not only important to Medicare beneficiaries and providers, but also to other purchasers/insurers whose policies and procedures are often follow Medicare’s lead. |
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ACA AND HEALTH CARE QUALITY
Congress has passed a series of laws (including the ACA) designed to |
move the Medicare program to an active purchaser of high quality, high value healthcare.
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ACA AND HEALTH CARE QUALITY
The ACA’s vision for improving quality focuses on: |
quality measure development; quality measurement (including payment incentives); public reporting; and value-based purchasing.
Develop a National Quality Strategy |
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NATIONAL PRIORITIES FOR PUBLIC HEALTH IMPROVEMENTS
Public Health Primary Drivers of Quality (i.e., six priority areas): |
Population Health Metrics and Information Technology
• Evidence-Based Practices, Research, and Evaluation • Systems Thinking • Sustainability and Stewardship • Policy • Workforce and Education |
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RECOMMENDATIONS TO IMPROVE PUBLIC HEALTH
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• Improve the analysis of population health and move toward achieving health equity
• Improve program effectiveness • Improve methods to foster integration among all sectors that impact health (i.e., public health, health care, and others) • Increase transparency and efficiencies to become better stewards of resources • Improve surveillance and other vigilant processes to identify health risks and become proactive in advocacy and advancement of policy agendas that focus on risk reduction • Implement processes to advance professional competence in the public health workforce |
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What is public policy and who informs the process
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Authoritative decisions made in the legislative, executive, or judicial branches of government that are intended to direct or influence the actions, behaviors, and decisions of others
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How does it impact health care?
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Health policies have a meaningful role in the protection against injury, disease, disability, risk mitigation, and the reduction of disparities and exclusion One main focus in public health is finding the appropriate balance between population welfare and individual freedoms Public policy includes: 1.) statutes, formed through legislation 2.) judicial interpretations and decisions 3.) rules and regulations 4.) standard operating procedures 5.) results of initiative and referenda elections 6.) executive orders 7.) any type of decision by those in government on behalf of themselves or the public |
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How do legislative bills get passed?
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Representatives introduce bill in the House, bill is read in the house and assigned to a committee by the Speaker, bill leaves committee and is scheduled for floor consideration and debate and may be amended, House passes bill, Bill is sent to Senate Senator introduces bill in the Senate, bill is read in the Senate and is assigned to a committee by the Majority Leader, bill leaves committee and is scheduled for floor consideration and debate and may be amended, Senate passes bill, and bill is sent to House A conference committee is created to resolve differences if both chambers do not pass an identical bill, identical bill is passed by both House and Senate or branch agrees to the other branch's version or bill is ammended and both branches vote again and pass ammended version, bill is presented to the President, who has four options Option 1: President signs bill into law Option 2: During congressional session, bill becomes law after 10 days without presidential signature Option 3: When not in session, bill does not become law without the presidential signature Option 4: President vetoes bill, two-thirds vote in House and Senate can override veto *Most bills do not pass through the process the first time, but are revised and re-introduced in subsequent sessions. Sometimes it takes years for a bill to pass, if at all. |
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Know and understand the Longest’s Process of Public Policymaking
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Policy Formulation Phase: Preferences of individuals, organizations, and interest groups, along with biological, cultural, demographic, ecological, economic, ethical, legal, psychological, social, and technological inputs. Agenda setting: 1.) Problems 2.) Possible solutions 3.) Political circumstances Development of Legislation Window of opportunity - opens when there is a favorable confluence of problems, possible solutions, and political circumstances Policy Formulation Phase and Policy Implementation Phase are bridged by Formal Enactment of Legislation Policy Implementation Phase: Rule making Operation= Policy, which leads to feedback feedback = Policy Modification Phase: Feedback from individuals, organizations, and interests groups experiencing the consequences of policies, combined with the assessments of the performance and impact of policies by those who formulate and implement them, influences future policy formulation and implementation, this feeds into Policy Formulation and Policy Implementation Phases |
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What is the difference in policy making process versus policy implementation
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Policy Formulation: the process of defining, considering, and accepting or rejecting policy options. it involves decisions on what, if anything, should be done about a given problem and adoption of legislation or administration rules that appropriately enact the agreed upon principles the weighing of options takes into account various factors including: 1.) who benefits (the more the better) 2.) who might be negatively affected (the fewer the better) 3.) time required to implement the solution 4.) associated cost and financing 5.) political complexities Policy Formulation Phase and Policy Implementation Phase are bridged by Formal Enactment of Legislation Policy Implementation: 1.) Translates policy into action (programs, projects, interventions) 2.) Is crucial. A policy is generally useless if it isn't implemented. 3.) Transforms the legislative language into managerial and administrative action. 4.) Inadequate implementation contributes to reduce or failing the achievement of the established goals. |
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What are the federal, state and local responsibilities for health policy and implementation?
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State and federal regulations affects all facets of the delivery and financing of healthcare services States regulate: health insurance premiums and benefits covered; health professional licensing and their scope of practice; control of communicable diseases and environmental sanitation Police powers: state and local government authority to require individual conformance with established standards of conduct; standards are designed to promote and protect the public’s health, safety, and welfare, and to permit government control of personal, corporate, and other private interests |
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What are the individual’s rights in regards to receiving health care?
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U.S. is one of the only high-income nations that does not guarantee health care as a fundamental right “No-duty-to-treat” principle: Generally speaking, individuals have no legal right to health care services or to public health insurance and, correspondingly, there exists on the part of health care providers no general legal duty to provide care. Exception: The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law that requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay Individual Rights and the Health Care System Categorize health care rights in 3 ways: 1. Rights related to receiving services explicitly provided under health care, health financing, or health insurance laws. 2. Rights concerning freedom of choice and freedom from government interference when making healthcare decisions. 3. The right to be free from unlawful discrimination when accessing or receiving health care. |
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What are the two theories of government with respect to health policy
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• Public Interest Theory – legislation is enacted according to what legislators believe is in the public interest. • Economic Theory – legislators enact legislation for their own self interest. |
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Know the basics of supply and demand
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Demand is the quantity of goods and services that a consumer is willing and able to purchase over a specified time Common Demand Shifters: • Income • Quality (actual or perceived) • Price of the original good, price of a substitute good, and price of a complementary good Demand elasticity is the percentage change in the quantity demanded resulting from a 1% change in price or income. If a product is elastic a change in price/income will result in an equivalent or greater change in demand. If a product is inelastic demand for the good is not sensitive to a change in price/income. Supply is the amount of goods and services that producers are able and willing to sell at a given price over a given period of time. Common supply shifters: • Input costs • Sale price • Number of sellers • Change in technology Suppliers are driven to maximize profit. In a competitive market, profit is maximized at the level of output where marginal cost equals price. Equilibrium exists in the market when there is a balance between the quantity supplied and the quantity demanded. Supply elasticity is the percentage change in quantity supplied resulting from a 1% increase in the price (or other variables, such as inputs) of buying the good. If a product is elastic a change in price (or other variables) will result in an equivalent or greater change in supply. If a product is inelastic supply of the good is not sensitive to a change in price (or other variables). |
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Types of market structures
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Monopolies: Single seller controls market Oligopolies: Few dominant firms, substantial barriers to entry Monopsonies: Few consumers who control price paid to sellers Health care is a monopolistically competitive market • Few dominant firms with significant market power and many smaller firms without market power |
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How health insurance effects the supply/demand relationship
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The presence of health insurance may impact a provider’s willingness to supply goods and services Health Insurance and Supply Competing concerns:
• Providers act as patient’s agent and act in patient’s best interest • Providers may have a financial incentive to act or refrain from acting in a certain way due to insurance arrangements or the lack of insurance. Health insurance acts as a buffer between the: consumer and cost of health care goods and services • Goods and services cost the consumer less than the charged price because of the presence of health insurance Moral Hazard • Because a consumer does not pay the full cost of a good, the consumer may purchase more than goods than he would otherwise purchase without insurance |
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Market failure
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resources are not produced or allocated efficiently |
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What is federalism and how does it effect public health programs
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Federalism in the United States is the constitutional relationship between U.S. state governments and the federal government of the United States. Federalism is a system of government in which the same territory is controlled by two levels of government. Generally, an overarching national government governs issues that affect the entire country, and smaller subdivisions govern issues of local concern. Both the national government and the smaller political subdivisions have the power to make laws and both have a certain level of autonomy from each other. The United States has a federal system of governance consisting of the national or federal government, and the government of the individual states. Federal and state policy and law shape virtually all aspects of the the healthcare system, from structure and organization, to service delivery, financing, and administrative and judicial oversight State and federal regulations affects all facets of the delivery and financing of healthcare services Federalism has implications for public health practice: it molds financing and disbursement options, including funding formulas, which affect allocations and program goals, and shapes how funding decisions are operationalized in a political context. |
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Basics of health insurance and terminology
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Health care transaction with an insured patient involves three parties: • Consumer (patient) • Supplier (provider) • Insurers States regulate: health insurance premiums and benefits covered; health professional licensing and their scope of practice; control of communicable diseases and environmental sanitation Beneficiary: Consumer, individual who is covered by the plan Premium: An annual fee paid by the beneficiary to the health plan, usually in monthly installments, to secure health insurance coverage Deductible: An amount of money a beneficiary must pay out-of-pocket before the insurance company assists with paying for services. Cost-sharing: Co-payment or co-insurance, an amount the beneficiary pays per service after the deductible is met |
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What is managed care and the different types of managed care
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Managed care integrates the provision and payment of health care services. Ideally, managed care contains costs while providing necessary and high quality health care services. Some fear that managed care companies provide fewer services than necessary or lower quality services to save money. Managed Care – Cost Containment Tools Performance-based salary bonuses and withholds Performance-based salary bonuses and withholds • Provider receives a salary as a managed care organization employee • Salary is subject to bonuses or withholds Gatekeeper - Managed care organization uses a primary care provider to make sure only necessary and appropriate care is provided Utilization review - Managed care organization reviews and approves or denies services requested by provider Case management - Managed care organization manages and coordinates patient care 1.) Health Maintenance Organization (HMO): • Pays providers a salary or capitation • Beneficiaries may only use in-network providers • HMO coordinates and controls receipt of services 2.) Preferred Provider Organization (PPO): • Pays provider on a discounted fee schedule • Beneficiary may use in- or out-of-network providers 3.) Point of Service Plans (POS): Combines features of HMO and PPO • Pays providers with capitation or other risk sharing arrangement• Has a provider network; beneficiaries may use out-of-network provider for designated services • Has a gatekeeper to control and coordinate care |
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Medicaid structure, eligibility, and benefits
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Medicaid is a federal-state public health insurance program for the indigent.
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Medicare structure, eligibility, and benefits
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Medicare is a federally-funded health insurance program for the elderly and some persons with disabilities. Medicare is administered by CMS. Structure: Medicare split into 4 parts, each with its own set of benefits:
Benefits: Part A: Hospital Insurance - Inpatient hospital, skilled nursing facility, hospice • Part B: Supplemental Medical Insurance - Physician services, outpatient services, limited preventive services • Part C: Managed Care - Same services (sometimes receive additional services) delivered through a managed care arrangement; Part C includes other types of plans as well • Part D: Prescription Drug Coverage - May receive through private drug plans or managed care arrangement Eligibility: Medicare covers two main populations – elderly and disabled Elderly requirements: • At least 65 years old • Eligible for Social Security by having worked and contributed to Social Security for at least 10 years Disabled requirements: • Individual is totally and permanently disabled and has received Social Security Disability Insurance for at least 24 months OR• Has End Stage Renal disease |
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CHIP
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A block grant program designed to provide health insurance to low-income children whose family income is above the Medicaid eligibility level in their state Reauthorized in 2009 and extended in the ACA; Authorization through 2019, funding through 2015 |
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ACA impact on Medicare and Medicaid
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Medicare: New coverage for preventive services without cost sharing, Eventually closes Part D doughnut hole • Short-term relief as well Reimbursement changes for hospitals and physicians Cost changes to beneficiaries Medicaid Expansion : •States to expand Medicaid program to include individuals up to 138% of FPL •June 2012, U.S. Supreme Court upheld the constitutionality of the law including the individual mandate but made the Medicaid expansion a state option. |
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History of health reform in the US
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•1912 Progressive Party candidate Teddy Roosevelt supported social insurance platform that included health insurance •1915 American Association for Labor Legislation proposal for working class health insurance •President Truman supported national health reform upon taking office, won re-election on national health insurance platform in 1948 •President Nixon initial health reform proposal in 1969 and revised proposal in 1972 •President Clinton Health Security Act in 1993 |
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Key elements of Affordable Care Act and why it was enacted?
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Uninsured becoming an economic burden for the whole country and employers concerned about rising healthcare costs Individual Mandate: •most Americans are required to have health insurance with “minimum essential coverage” or face a penalty. Insurance Exchanges: •states and federal government establish marketplaces where individuals and small businesses can purchase insurance. Role and Obligation of Employers: companies with more than 50 employees must offer health insurance to employees or face a $2,000 fine per employee.
Medicaid Expansion: •States to expand Medicaid program to include individuals up to 138% of FPL New Rules for Insurance Companies: •limit the ability to deny coverage for any reason such as health status or pre-existing condition and children can be covered under parents plan through the age of 25 regardless if in college. New approaches to healthcare delivery: •recognizes the importance of cost and quality in healthcare delivery •Public health initiatives •Information technology advancements •Delivery systems reforms (Accountable Care Organizations, different payment models) |
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Changes in the health insurance market due to the ACA
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•No pre-existing condition exclusion •Dependent coverage to age 26 •Preventive services without cost sharing •Prohibitions against lifetime and annual coverage limits •No rescission without fraud •New appeals process •Premium rate reviews •Guaranteed issue and renewability •Rate variation limits •Essential health benefits •Wellness plans |
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ACA legal challenges
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•Many states filed a suit to stop the implementation of the ACA (including Florida). •Concerns over constitutionality as well as states rights being over-ridden by federal government. •Main issues were the individual mandate for everyone to have health insurance and the expansion of Medicaid. •June 2012, U.S. Supreme Court upheld the constitutionality of the law including the individual mandate but made the Medicaid expansion a state option. |
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The scope and causes of medical errors
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Although medical errors are not a new problem,framing the issue as a public health problem is a relatively new phenomenon. Overall, more people die each year from medical errors than from motor vehicle accidents, breast cancer, or AIDS. Key causes of errors affecting patient safety in hospitals: . Medication Errors • Infection Control • Injuries from falls • Injuries from procedures Other causes of medical errors may include: 1. failure to complete an intended medical course of action or implementing the wrong course of action, 2. using faulty equipment or products in effectuating a course of action, 3. failing to stay abreast of one’s field of medical practice, 4. health professional inattentiveness or negligence, 5. optimal treatments for many illnesses are not yet known, and 6. the culture of medicine itself |
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Structural elements to improve quality of care
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RECOMMENDATIONS TO IMPROVE PUBLIC HEALTH: • Improve the analysis of population health and move toward achieving health equity • Improve program effectiveness • Improve methods to foster integration among all sectors that impact health (i.e., public health, health care, and others) • Increase transparency and efficiencies to become better stewards of resources • Improve surveillance and other vigilant processes to identify health risks and become proactive in advocacy and advancement of policy agendas that focus on risk reduction • Implement processes to advance professional competence in the public health workforce NATIONAL PRIORITIES FOR PUBLIC HEALTH IMPROVEMENTS: Public Health Primary Drivers of Quality (i.e., six priority areas): . Population Health Metrics and Information Technology • Evidence-Based Practices, Research, and Evaluation • Systems Thinking • Sustainability and Stewardship • Policy • Workforce and Education |
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Medical negligence
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legal standard used in medical negligence cases to determine whether health professionals and entities have adequately discharged their responsibility to provide reasonable care to their patients. |
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Efforts to measure and incentivize high quality health care
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Providers may have a financial incentive to act or refrain from acting in a certain way due to insurance arrangements or the lack of insurance. quality measure development; quality measurement (including payment incentives); public reporting; and value-based purchasing. Develop a National Quality Strategy |
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Public health quality improvement goals
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Institute of Medicine -Crossing the Quality Chasm: A New Health System for the 21st Century (2001) Outlines 6 areas for improvement: safety effectiveness patient centered care timeliness of care efficiency of delivery of care equitable provision of care |
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10 Essentials of Public Health |
Assessment: 1.) Monitor Health 2.) Diagnose and Investigate Policy Development: 3.) Inform, Educate, Empower 4.) Mobilize Community Partnerships 5.) Develop Policies Assurance: 6.) Enforce Laws 7.) Link to/Provide Care 8.) Assure Competent Workforce 9.) Evaluate System Management: 10.) Research |
