u.s. healthcare system overview in 90 minutes or less stakeholders major challenges
Post on 19-Dec-2015
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U.S. Healthcare System
• Overview in 90 minutes or less
• Stakeholders
• Major challenges
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STAKEHOLDERS
• Patients/clients/customers
• General Public
• Employers
• Governments
• Insurance Plans
• Providers
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CHANNEL OF DISTRIBUTIONINPATIENT SURGERY
CONSUMER
INSURER
PCP
SURGEON
HOSPITAL
EMPLOYER
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PER CAPITA HEALTH EXPENDITURES
0
500
1000
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3000
3500
4000
4500
U.S. Norway Austria U.K. Poland
1999
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HEALTH CARE TRIANGLE
COST
QUALITY ACCESS
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Total U.S. Health Expenditures
0
200
400
600
800
1000
1200
1400
1600
1800
1965 1970 1980 1990 2000 2005
$ Billions
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STAKEHOLDERS: THE PUBLIC
• Potential patients
• Taxpayers
• Purchasers of other goods and services
• Expectations?– Is health care a right like public education or
police protection?
• When do they show interest?
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Projected Growth in U.S.Population Age 65 and Older
0
10
20
30
40
50
60
70
1980 1990 2000 2010 2020 2030
Millions
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STAKEHOLDERS:EMPLOYERS
• Pay most of the private insurance premiums
• Taxpayers
• Competing for workers
• Competing globally for markets
• >10% premium increases
• How are they coping?
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STAKEHOLDERS:GOVERNMENTS
• DOMINANT PAYER (ABOUT 50%)– Medicare, Medicaid, VA
• HUGE REGULATOR– Federal, State, Local
• DIRECT PROVIDER– VA– State hospitals, clinics, health departments– County/City hospitals, clinics, health departments
• POLITICS
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STAKEHOLDERS:INSURANCE PLANS
EVOLUTION• 1930’s—Blue Cross• POST WW2—Rapid growth of employer based
plans• 1980’s—Managed Care• Integrated networks
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STAKEHOLDERS:INSURANCE PLANS
FUNCTIONS
• Develop coverage plans
• Contract with providers
• Market the plans
• Underwrite
• Manage utilization, quality, cost
• Administer claims
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STAKEHOLDERS:INSURANCE PLANS
STATUS• Cyclical profit and loss • Return to rapid premium increases• Consolidation• Backlash against controls
– Consumers
– Politicians
– Courts
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STAKEHOLDERS:INSURANCE PLANS
KEY ISSUES• Control total cost
– Number of services used
– Cost per unit of service
• Manage (shift) the risk• Satisfy consumers, regulators, courts
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STAKEHOLDERS:PROVIDERS
• HOSPITALS• OUTPATIENT CENTERS• PHYSICIANS• OTHER CLINICIANS• LONG-TERM CARE• MENTAL HEALTH• PUBLIC HEALTH
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HOSPITALS
HISTORY
1873 178
1909 4,300
1946 6,000
1970’S 7,200
2000’S <4,000
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HOSPITALS
STATUS• Losing money• Upward pressure on costs
– Critical staff shortages– Legislative/judicial mandates– Insurance premiums
• Increasing inpatient volume• Competition for outpatients
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Inpatient Admissionsin Community Hospitals
28
29
30
31
32
33
34
35
36
37
1980 1985 1990 1995 2000 2003
Millions
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HOSPITALS
CHALLENGES• Reposition philosophy, organization, facilities
– Emergency, Critical Care, outpatient services
• Re-establish partnerships with physicians• Continue to invest in technology• Employer of choice, again• Public accountability and confidence• Advocate national health policy: fix payment syst.
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OUTPATIENT CENTERS
• START WITH: GP’s office, Hospital indigent clinics, Hospital ER’s, public health clinics
• ADD: Group practices, Hospital outpatient departments, specialty clinics
• NOW: Freestanding centers– Primary care, urgent care, surgery, imaging, eye
treatment, gastro-intestinal, and on and on
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OUTPATIENT CENTERS
STATUS
• Burgeoning volume (Why?)
• Diverse ownership
• Increasing regulatory and insurance plan scrutiny
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OUTPATIENT CENTERS
CHALLENGES
• Anticipate technology changes
• Maintain quality and public confidence
• Maintain profitability with lower payments
• Increasing competition
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PHYSICIANS
EVOLUTION:
Doc-in-a-buggy to Doc-in-a-box
• Solo practice
• Group
• Multi-specialty group
• Employee
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PHYSICIANS
STATUS• 60 to 70% Specialists, most clustered around
Academic Medical Centers• Not enough Primary Care in many places• Dramatic decline in payments• Baby boomers retiring: shortages ahead?• Lost power to insurance plans• Cost pressure: labor, insurance premiums, regs
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PHYSICIANS
CHALLENGES
• Re-establish control of patient care
• Negotiate better payments/contracts
• Reform malpractice liability system
• Anticipate changes in technology and competition; establish long-term position
• Replace retiring colleagues
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LONG-TERM CARE
EVOLUTION
• Mom and Pop rest homes
• Neglect and abuse scandals: regulation
• Corporate owned skilled nursing facilities
• Diversity in settings and types of patients
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LONG-TERM CARE
STATUS• SNF’s
– Declining occupancy last 15 years• Older adults healthier• Vast increase in options• Federal prospective payment
– Will reverse with dramatic increase in numbers of “super-elderly” over next 25 years
– Medicaid is largest payer
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LONG-TERM CARE
• Assisted living– Rapid growth: expect to double by 2025– Often part of retirement community– Private pay
• Adult Day Care– Another option; small but growing– Private pay
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LONG-TERM CARE
• Home care– Fastest growing segment of U.S. health – Mix of long and short-term– Medicare is largest payer, cutting payments
• Hospice– Offered in many settings– Growing recognition of value – Medicare pays
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LONG-TERM CARE
CHALLENGES• Demographics: over 65 will double from year
2000 to 2030; over 85 will increase more rapidly• Family changes: career women, or 70 year old
“child” unable to care for 90 year old parent• Technology: extends life, diversifies care options
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LONG-TERM CARE
CHALLENGES (continued)• More sophisticated consumers: aware of
options• Government scrutiny: pressure for high
quality; budget crunches• Labor shortages: traditionally lower pay and
benefits than hospitals and outpatient centers
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MENTAL HEALTH
HISTORY: Grim and grimmer• Locked in asylums (or worse)• 1930’s to early 60’s: development of shock
therapies and first effective drugs increased ability to manage inpatients
• 60’s to 80’s: Community mental health centers; reduced funding for inpatients; marketing competition for private dollars
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MENTAL HEALTH
STATUS
• Tremendous capabilities to specifically diagnose and effectively treat most forms of severe mental illness
• Only half of severe and persistent mentally ill receive treatment
• Insurance coverage significantly limited
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MENTAL HEALTH
CHALLENGES
• Stigma, misperceptions
• Unresolved public policy debate: maintaining mental health VS. treating severe and persistent illness
• Insurance limitations resulting from above
• Patient compliance with treatment
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PUBLIC HEALTH
EVOLUTION
• Sanitary reform
• Epidemic control
• Prevention, education, immunization
• Unable to compete with M & M for funds
• Renewed interest because of terrorism, new viruses
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PUBLIC HEALTH
STATUS
• Less than 1% of U.S. health dollars are spent for public health
• Greatly increasing public demand for management of new diseases, water supply, food supply, and more
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PUBLIC HEALTH
CHALLENGES
• Strong cultural bias favoring cure of the individual over promotion of the general health of the population
• Convert current public concerns into political clout for increased funding