health insurance. objectives for today explain the origins of insurance differentiate among types of...
TRANSCRIPT
![Page 1: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/1.jpg)
Health Insurance
![Page 2: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/2.jpg)
Objectives for today
Explain the origins of insurance
Differentiate among types of insurance
Explain reimbursement mechanisms
Explain service use incentives
Identify provider incentives
![Page 3: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/3.jpg)
What is insurance?
A method of distributing risk
Traditional insurance for expensive potential losses car accidents, hospitalization
Today’ health insurance covers fairly non-risky events routine physician care
![Page 4: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/4.jpg)
Origins of health insurance
European industries Germany’s sickness fund, 1840
United States Blue Cross: Baylor teachers in Dallas, 1929 American Medical Association opposed Blue Cross: expanded during depression Blue Shield: California Medical Society,
1939
![Page 5: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/5.jpg)
Health insurance types
Voluntary Individuals, employers purchases
Social health insurance Government sponsored (e.g. Medicare in
the U.S.; health insurance in Canada)
Public welfare For low income persons (e.g. Medicaid)
![Page 6: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/6.jpg)
Health insurance coverage in U.S.
41.7 million Americans (15.6 % of population) uninsured in 1996 (Carrasquillo et al. 1999; from Current Population Survey)
Texas has the higher proportion of uninsured of all of the states 4,680,000 Texans (24.3 %) uninsured a significant increase from 1989
![Page 7: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/7.jpg)
Health insurance coverage in U.S.
187.9 million (70.4%) covered
by private insurance 31.9 million (11.8%) covered
by Medicaid 34.7 million (13.2%) covered
by Medicare (13.2%)
![Page 8: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/8.jpg)
Health insurance coverage in U.S.by Age Category
14.8
22.7
14.4
1.1
0
5
10
15
20
25
<18 18-39 40-64 >64
% uninsured
![Page 9: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/9.jpg)
Health insurance coverage in U.S.by Gender
17.1
14.2
0
2
4
6
8
10
12
14
16
18
Male Female
% uninsured
![Page 10: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/10.jpg)
Health insurance coverage in U.S.by Race/Ethnicity
11.5
21.6
33.6
0
5
10
15
20
25
30
35
40
Non-HispanicWhites
Blacks Hispanics
% uninsured
![Page 11: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/11.jpg)
Voluntary health insurance
Most people in U.S. covered by private insurance
Employer purchased
Self-employed
Medigap
![Page 12: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/12.jpg)
Social health insurance programs in the U.S.
Worker’s compensation Medicare
Medicaid
Department of Defense
VA health system (not simply an insurance system, but a health system)
![Page 13: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/13.jpg)
Source of expenditures
31%
4%
19%14%
13%
19% Private healthinsuranceOther private
Medicare
Medicaid
Other gov't.
Out of pocket
![Page 14: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/14.jpg)
Where the $1 trillion is spentfrom Levit et al. (1996)
11%
36%
8%
20%
25% Other spending
Hospital care
Nursing home
Physician services
Other personalhealth care
![Page 15: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/15.jpg)
Worker’s compensation
Covers employed persons
Pays cash replacement of a portion of wages
Pays for medical care resulting from work-related injury or sickness
![Page 16: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/16.jpg)
Medicare
An entitlement program passed in 1965
The major social health insurance program in the U.S.
Covers individuals 65 and older Also covers disabled individuals and
those with end-stage renal disease
![Page 17: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/17.jpg)
Medicare Part A
Compulsory
Covers hospital costs
Paid for by Social Health Insurance Trust Fund
Indirect payment Gov’t. does not own provider
organizations and does not hire providers
![Page 18: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/18.jpg)
Medicare Part A Benefits
90 inpatient days in a benefit period Deductibles for days 1-60
Coinsurance for days 61-90
100 days in Skilled Nursing Facility Coinsurance
![Page 19: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/19.jpg)
Medigap
70 % of Medicare enrollees have supplemental insurance Covers deductibles, coinsurance
![Page 20: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/20.jpg)
Medicare Part B
Not compulsory
Covers physician services
Most $ from general treasury
Some $ from Social Security check deductions for Part B
![Page 21: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/21.jpg)
Medicare Part B Benefits
Physician services Yearly deductible Monthly premium
Outpatient hospital care
No pharmaceuticals
No eye examinations
![Page 22: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/22.jpg)
Medicaid (Title XIX)
A welfare or charity program
Most $ comes from U.S. General Treasury
State treasuries pick up rest of tab
![Page 23: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/23.jpg)
Medicaid (Title XIX)
Eligibility requirements
Receiving Aid to Families with Dependent Children (AFDC)
Pregnant and postpartum women with children < 6 yrs. and income < 133% of poverty level
Aged, blind, and disabled receiving supplemental security income
![Page 24: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/24.jpg)
Medicaid Benefits
Hospital inpatient care
Home health care
Physician services
Family planning
Other services as shown in text
![Page 25: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/25.jpg)
Department of Defense
Military health care system for uniformed military personnel
CHAMPUS - Civilian Health and Medical Program of the Uniformed Services for families and dependents of active
military personnel
![Page 26: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/26.jpg)
VA Health Care System
For retired, disabled, and other “deserving” veterans approximately 170 hospitals in
U.S. provide mostly acute hospital care some specialized outpatient care mental health care long term care
![Page 27: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/27.jpg)
Moral hazard
When have insurance, want to reap the benefits of it
Can lead to excess use of health services
To control effects of moral hazard, multiple techniques used
![Page 28: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/28.jpg)
TEFRA
Tax Equity and Fiscal Responsibility Act (1982)
Encouraged Medicare HMOs
Prospective payment for Medicare (DRGs)
![Page 29: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/29.jpg)
RBRVS
Resource-based relative-value scale (1992)
for Medicare Part B
Based on physician work, practice expense, and malpractice insurance
![Page 30: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/30.jpg)
Controlling excess use
In the U.S., we tend to rely on risk distribution and market incentives
Patient incentives (cost sharing)
Provider incentives (reimbursement)
Utilization review
Health plan competition
![Page 31: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/31.jpg)
Patient incentives: Deductibles
Money that must be paid by the individual before insurance benefits kick in
e.g. the patient must pay for $500 of medical charges before insurance begins to pay
Criticized for contributing to delays in treatment
![Page 32: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/32.jpg)
Patient incentives
Copayment Fixed amount paid for each service consumed e.g. a patient has to pay $15 every time
he/she visits a physician
Coinsurance A percentage of money paid by individual for
each service e.g. the insurer pays 80% of surgery charges;
the patient pays 20%
![Page 33: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/33.jpg)
Physician reimbursement
Fee-for-service (FFS)
Prepayment
Salary
![Page 34: Health Insurance. Objectives for today Explain the origins of insurance Differentiate among types of insurance Explain reimbursement mechanisms Explain](https://reader035.vdocuments.net/reader035/viewer/2022062308/56649e445503460f94b3791a/html5/thumbnails/34.jpg)
Utilization review
Prospective
Retrospective
Concurrent