HSCI 678 Intro to US Healthcare System Future Directions in the US Health Services Delivery System Chapter 21 Tracey Lynn Koehlmoos, PhD, MHA

Cost-Quality-Access ACCESS QUALITYCOST What changes? Who will be effected? Why?

Financing Changes Economic Support Component—changes here directly impact health service delivery Public Financing—Medicare and Medicaid –Gradual climb to being #1 payer –2016, Medicaid Part A, expenditures > revenue –2029, Part A Trust Fund, bankruptcy! –Part B, 75% from general federal funds, growing –Part D, will it boost Medicare expenditures?

More Financial Changes Increased out-of-pocket Higher deductibles, increased co-pay Backlash against Managed Care Consumers will pay more Reductions in health insurance benefits Quest for new payment mechanism between FFS and capitation

Delivery System Changes The pendulum has swung toward increasing capacity (ex. ER services) MCOs changes due to cost inefficiency –Curbing prior authorization process –Reevaluating gatekeeper functions

Changes in Access Need to measure the full impact of: –HIPAA (1996)—small businesses may still find offering health insurance too costly –MHPA (1996)—Mental health coverage is NOT equal to physical health coverage—no replacement act since 2001 –SCHIP (1997)—Slow enrollment in some states Proportion of uninsured: STILL 15-20%

Changes in Quality More focus, any improvement? AHRQ: evidence-based health services QIOs (Quality Improvement Orgs): CMS switch from focusing on blame to focusing on performance improvement IOM: adverse events, avoidable death or disability Dismantling Managed Care: removes a platform of measuring quality

Changes in Cost? Do you really need to ask! March 2006: Access to the accurate cost of procedures –Through companies like HealthGrade, Inc. –Allows for individuals to compare prices and encourages health savings accounts

Why are changes happening? Provider and consumer backlash against managed care Population demographics Advent of new technologies Likely to see incremental rather than monumental change

Effects of Change on Consumers Insured: –Involuntary changes of insurance plan, providers –Higher cost sharing, decreased dependent coverage UnInsured: –Still no access to primary care –Less uncompensated care –Rigorous screening at ERs.

Effects of Change on Providers Doctor as frustrated businessman Switch to outpatient services Loss of autonomy Advent of the Hospitalist Provider payment decreases (Medicare and Medicaid) Rising malpractice insurance costs

Effect of Changes on Payers Employers and Medicare/Medicaid Frustrated by higher costs Frustrated by burgeoning delivery system More likely to use cost sharing methods

Effects of Change on Health Insurers Are they really the villains? Double digit increases in premiums—to cover the cost of paying for services Private companies looking to reduce risk Move to high deductible plans Move toward reduce benefits packages

Future Direction The only constant is CHANGE No viable solution to fix the problem of the uninsured Medicare Part D, what impact? Increased cost sharing, likely

Conclusion How much do we value choice? Is access to basic health services a right? To what extent does controlling access and containing expenditures jeopardize the provision of high quality service? There are no quick answers—but as health service leaders we must always be aware of the changing healthcare environment.