© 2006 thomson-wadsworth chapter 9 health care systems and policy

© 2006 Thomson-Wadsworth

Chapter 9

Health Care Systems and Policy


Learning Objectives

• Describe factors affecting the cost and delivery of health care.

• Explain why health promotion is a major component of the rhetoric about health care reform at the national level.

• Differentiate between traditional systems of health care and managed forms of health care.


Learning Objectives

• Describe eligibility requirements for and services provided to recipients of Medicare and Medicaid.

• Identify consumer trends affecting health care.

• State the value of using medical nutrition therapy protocols to document client outcomes in various health care settings.


Introduction

• In 2000, Americans spent more than $1.2 trillion for health care which represents over 13% of the gross national product.

• This amount exceeds the average amount spent by any other industrialized country.


Introduction

• Public policy is attempting to direct our medical system toward health promotion although Medicaid and Medicare and other major third-party payers offer limited reimbursement for preventive procedures.

• Many studies show that early detection and intervention, immunization, and behavior change could significantly reduce many of the leading causes of death and disability.


An Overview of the Health Care Industry

• Two general categories of health insurance in the United States: – Private

• Traditional fee-for-service• Group contract

– Public• Medicare• Medicaid• State Children’s Health Insurance

Program


Private Insurance

• Approximately 70.2% of Americans have private insurance.

• Private insurance can be in the form of traditional fee-for-service insurance or group contract insurance.


Private Insurance

• Traditional Fee-for-Service Plans– Include a billing system in which the

provider charges a fee for each service rendered.

– Critics of this plan claim that they encourage physicians to provide more services than necessary.

– Proponents prefer the greater flexibility and unrestricted access to physicians, tests, hospitals, and treatments.


Private Insurance

• Group Contract Insurance– Managed-care systems, represented by

health maintenance organizations (HMOs) and preferred provider organizations (PPOs), are prepaid group practice plans that offer health care services through groups of medical practitioners.

– The goal of managed care is improved quality of care with decreased cost.

– 91% of employees with health insurance were enrolled in managed-care plans in 1999.


Private Insurance – Group Contract Insurance

• HMOs provide comprehensive services across the continuum of care and they make money by keeping people healthy.

• Prepaid group health plans emphasize health promotion since they provide health care services at a preset cost.

• By keeping people healthy, HMOs avoid lengthy hospitalizations and costly services.



• General HMO models:– Staff model– Group model– Network model– Independent practice association

(IPA)– Point-of-service (POS) plan



• In some HMOs, provider receives a capitation payment– Capitation payment – A

predetermined fee paid per enrollee per month to the provider


Public Insurance

• Medicare and Medicaid - administered by the Centers for Medicare and Medicaid Services (CMS)

• State Children’s Health Insurance Program


The Medicare Program

• Medicare is the largest health care insurer in the U.S.

• It is designed to assist: – People 65 and older– People of any age with end-stage renal

disease– People eligible for Social Security disability

payment programs for more than 2 years– Qualified railroad retirement beneficiaries

and merchant seamen



• Medicare consists of two separate parts: – Hospital insurance (Part A)– Medical insurance (Part B)



• Medicare Part A – Provides hospital insurance benefits

that include up to 90 days of inpatient care annually with a 20 percent coinsurance fee.

– Hospital inpatient charges are reimbursed according to prospective payment system known as diagnosis related groups (DRGs).



• Medicare Part B – An optional insurance program financed

through premiums paid by enrollees and contributions from federal funds.

– Enrolled Medicare Medical Nutrition Therapy (MNT) providers are able to bill Medicare for MNT services provided to beneficiaries with type 1, type 2, and gestational diabetes, nondialysis kidney disease, and post-kidney transplants.



• Coverage Gaps• Medicare Modernization Act• Medicare Advantage Plan


The Medicaid Program

• Medicaid is a joint state and federal program that provides assistance with medical care for:– Eligible, low-income persons– Certain low-income pregnant women and

children– The aged, blind, and people with disabilities– Members of families with dependent

children in which one parent is absent, incapacitated, or unemployed



• The individual states define eligibility, benefits, and payment schedules.

• Typically, one must meet three criteria, including income, categorical, and resource.



• Medicaid covers a variety of services and settings, including inpatient and outpatient hospital services, physicians’ services, skilled nursing home and home health services, and laboratory and x-ray tests.

• To date, 36 state Medicaid programs cover certain forms of nutrition services provided by dietitians.


The State Children’s Health Insurance Program

• The State Children’s Health Insurance Program (SCHIP) is the largest single expansion of health insurance coverage for children in more than 30 years.

• States have flexibility in targeting eligible uninsured children.

• Many of the children served come from working families with incomes too high to qualify for Medicaid but too low to afford private health insurance.


SCHIP Enrollment,1999-2003


The Uninsured

• The uninsured include the working poor and those who work for small businesses.

• The employed uninsured number 15 million.


The Uninsured

• The non-working uninsured number 9 million and include: – The homeless– Some deinstitutionalized mentally ill

patients– Low-income people who do not

qualify for Medicaid


% of U.S. Persons without Health Care Coverage, 2003


Demographic Trends and Health Care

• By the year 2030, the baby boom will become a senior boom with 21 percent of the population over 65 years of age.

• Racial and geographical factors in the population are also important to the shape of the future.


The Need for Health Care Reform

• Health care reform refers to the efforts undertaken to ensure that everyone in the U.S. has access to quality health care at an affordable price.



• Some of the challenges of health care reform include:– Making health care accessible to

everyone.– Containing costs.– Providing nursing home care to those

who need it.– Ensuring that Medicare and Medicaid

can serve all who are eligible.



• Cost, access, and quality are interrelated and manipulating one has an astounding impact on the others.

• Health care policy makers are studying alternative models of delivery and financing in hopes of applying other nations’ successes to the U.S.


The High Cost of Health Care

• Health care inflation is well established and the level of health care activity is expected to grow as a result of various factors including: – An aging population– Increased demand– Continuing advances in medicine


National Health Expenditures (Billions of Dollars)



• Major contributors to health care expenditures in the U.S. are: – The administrative cost of the

insurance process itself – Professional liability costs


The Nation’s Health Dollar, 2002



• Efforts at Cost Containment– Efforts to curb soaring health care

costs cover a broad spectrum... • from slowing hospital construction • to reducing length of hospital stays, and• increasing copayments and deductibles

for insured employees and Medicare recipients.


The High Cost of Health Care - Cost Containment

• One example of cost containment is the prospective payment system (PPS) that the federal government implemented.– The purpose of the PPS was to change

the behavior of health care providers by changing incentives under which care is provided and reimbursed.



• PPS (continued)– Prospective payment means knowing the

amount of payment in advance.– PPS uses diagnosis related groups

(DRGs) as a basis for reimbursement.– Patients are classified according to the

principal diagnosis, secondary diagnosis, sex, age, and surgical procedures.



• PPS (continued)– There are 23 categories and a total of

490 DRGs.– One consequence of PPS has been an

increased focus on outpatient services.



• Equity and Access as Issues in Health Care– Public opinion polls in the U.S. reveal

that most people believe all citizens are entitled to access to health care...

– but debate continues about the acceptable level of health care and what benefits should be included.


The High Cost of Health Care – Equity and Access

• Racial and Ethnic Disparities in Health– A recent report released by DHHS

shows significant improvements in the health of racial and ethnic minorities but also indicates that important disparities in health persist.


Health Care Reform in the United States

• Almost all industrialized countries except the U.S. have national health care programs.

• In these systems, coverage is generally universal and uniform and costs are paid entirely from tax revenues or by some combination of individual and employer premiums and government subsidization.



• Health care reform in the U.S. raises a formidable list of issues including: – Overall cost containment– Universal access– Emphasis on prevention– Reduction in administrative

superstructure and costs



• While the government remains undecided on what kind of health care system is needed or how to pay for it, health care reform is evolving at an accelerating rate without legislation.


Nutrition as a Component of Health Care Reform

• Many believe that nutrition services are the cornerstone of cost-effective prevention and are essential to halting the spiraling cost of health care.



• The American Dietetic Association (ADA) has urged that nutrition services be included in any health care reform legislation.

• Registered dietitians also need to be recognized as the nutrition experts of the health care team.



• Cost-Effectiveness of Nutrition Services– ADA encourages all of its practitioners

to document the cost-effectiveness of nutrition services.

– Cost-effectiveness studies compare the costs of providing health care against a desirable change in patient health outcomes.



• Cost-Effectiveness (continued)– Effective nutrition therapy can produce

economic benefits as a result of altered food habits and risk factors.

– Practice guidelines or protocols that clearly specify appropriate care and acceptable limits of care for each disease state or condition are important to enhance the quality, efficiency, and effectiveness of the health care system.



• Care delivered according to a protocol has been linked with positive outcomes for the client.

• Examples of outcomes include: – Measure of control (serum lipid profiles)– Quality of life– Dietary intake– Patient satisfaction


Measurable Outcomes of Nutrition Intervention



• Developing standardized protocols of care for nutrition intervention is considered a must for achieving payment for nutrition services and expanding current levels of third-party reimbursement.


Medical Nutrition Therapy and Medicare Reform

• The ADA believes that reimbursement for nutrition services through Medicare and Medicaid is inadequate.

• ADA supports the inclusion of medical nutrition therapy as a covered benefit in all types of health care delivery.


Medical Nutrition Therapy Providing Return on Investment

• Oxford Health Plan – Saved $10 for every $1 spent on nutrition

counseling for at-risk elderly patients

• The Lewin Group– 8.6% reduction in hospital utilization for patients

with CVD– 16.9% reduction in physician visits for patients

with CVD– 9.5% reduction in hospital utilization for diabetes

patients– 23.5% reduction in physician visits for diabetes

patients


Medical Nutrition Therapy Providing Return on Investment

• University of California Irvine– Lipid drug eligibility was obviated in 34 of 67

subjects– Estimated annual cost savings from the

avoidance of lipid medication was $60,652

• Pfizer Corporation– Projected $728,772 annual savings from

reduced cardiac claims

• U.S. Department of Defense– Saved $3.1 million the first year for CVD

patients


Evaluating Nutrition Risk in Older Adults

• NSI DETERMINE Checklist - a nutrition screening tool to help identify warning signs of potential nutrition problems.



• “Determine Your Nutritional Health” Checklist– I have an illness or condition that made me

change the kind or amount of food I eat.– I eat fewer than two meals each day.– I eat few fruits or vegetables or milk

products.– I have three or more alcoholic drinks almost

every day.– I have tooth or mouth problems that make it

hard for me to eat.



• “Determine Your Nutritional Health” Checklist (continued)– I don’t always have enough money to buy

the food I need.– I eat alone most of the time.– I take three or more different prescribed or

over-the-counter medicines a day.– Without wanting to do so, I have lost or

gained 10 pounds in the last 6 months.– I am not always physically able to shop,

cook, and/or feed myself.



• Campaign Long-Term Nutrition Risk Reduction – Demonstrates how nutrition screening

and case management can help lower nutrition risk among frail, homebound older adults.



• Goals and Objectives– Improve the nutritional status of frail,

homebound older adults receiving home services under the Medicaid Waiver Program by:

• Nutritionally screening clients• Providing home-based medical nutrition therapy

where indicated• Using a coordinated case management approach

to determine need for further services• Evaluating the effectiveness of home-based

medical nutrition therapy



• Methodology– Older adults contacted to complete

"Nutrition Screening Checklist"– Clients identified as “at risk” referred for for

an initial home visit and in-depth nutritional assessment

– MNT care plan devised and carried out– In-depth nutritional assessment repeated at

discharge



• Results– Semiannual samplings of 20% of all

discharged patients– 89% of clients surveyed lowered their

nutrition risk scores after receiving home-based medical nutrition therapy.


On the Horizon: Changes in Health Care and Its Delivery

• The future offers much that is positive for the profession of dietetics.

• Yet to be achieved are the effective provision and allocation of resources, such as nutrition services as part of preventive care.


On the Horizon: Changes in Health Care and Its Delivery

• A coordinated strategy for health care, political will, and active collaboration of both health care professionals and consumers of health care services will be required to achieve this goal.

• Health care reform for the U.S. is certain, but the exact nature of the reform will continue to evolve.


Ethics and the Nutrition Professional

• What Is Ethics?– A philosophical discipline that attempts to

determine what is morally good and bad, right and wrong

• Codes of Ethics– The ADA published its first code of ethics in

1942– Most recent code became effective in 1999– ADA code applies to all ADA members and

credentialed practitioners



• Guiding Principles– Autonomy - respecting the individual’s

rights of self-determination, independence, and privacy

– Beneficence - protecting clients from harm and maximizing possible benefits

– Non-maleficence - the obligation not to inflict harm intentionally

– Justice - striving for fairness in one’s actions and equality in the allocation of resources



• Health Promotion and Ethics• Ethical Decision Making

© 2006 thomson-wadsworth chapter 9 health care systems and policy

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