Welcome to HS Health Care Administration Tami Ford, M.A. Adjunct Faculty School of Health Sciences Kaplan University Unit

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Introduction to US Health Care Chapter 12 Managed Care Controlling Costs and Access to Health Services

Controlling Costs Controlling Access Referrals Type of care Specify provider Controlling Price Negotiate fees with in-network providers

Managed Care Features Utilization Reviews Provider Networks Preventive Care Reduction of Paperwork Copayments Gatekeeper Patients required to get approval from the organization before receiving certain services

Managed Care Features Utilization Reviews Provider Networks Preventive Care Reduction of Paperwork Copayments Gatekeeper Patients must use specific providers who have contracts with the organization

Managed Care Features Utilization Review Provider Networks Preventive Care Reduction of Paperwork Copayments Gatekeeper Comprehensive preventive care – cost effective

Managed Care Features Utilization Reviews Provider Networks Preventive Care Reduction of Paperwork Copayments Gatekeeper Members do not fill out claim forms Increased paperwork for providers

Managed Care Features  Utilization Reviews  Provider Networks  Preventive Care  Reduction of Paperwork  Copayments  Gatekeeper Flat fee at time of service

Managed Care Features  Utilization Reviews  Provider Networks  Preventive Care  Reduction of Paperwork  Coypayments  Gatekeeper Members must have referral from PCP to see specialist

Managed Care Organizations Health Maintenance Organizations (HMOs) Preferred Provider Organizations (PPOs) Point-Of-Service (POS) Plans

Managed Care Organizations Health Maintenance Organizations (HMOs) Links together a health plan, hospitals (closed or open arrangement), and physicians into a network (independent practice association/IPA model HMO, group model HMO, or staff model HMO)

Managed Care Organizations Preferred Provider Organizations (PPOs) Similar to HMOs, but do not PCP as gatekeepers Tend to require greater out-of-pocket payments from members

Managed Care Organizations Point-Of-Service (POS) Plans Combination of HMO and POS (choose each time) Encourage use of gatekeeper Choose out of network provider (with penalty)

Introduction to US Health Care Chapter 13 Promoting Health and Preventing Disease Challenges Facing the U.S. Health Care System

U.S. Health Care System Growing in complexity Advances in medical science and technology Evolving understanding of the human body Increase in demand for treatment

The Effect on Governing Boards Economic dynamics Burgeoning health care systems Higher expectations of accountability

Challenges Facing Health Systems Mergers and acquisitions have produced complex and unwieldy organizations Cost reductions have not been achieved Huge losses in various investments such as purchase of physician practices Integration of management systems has been problematic

Financing Health Care Health Care Costs Number of Insured Growing number of uninsured Enter system sicker = boost in cost General inflation Increased medical expense Increasing population Increase in demand

Funding Medicare Largest health plan and payer of hospital and physician services Rising costs and increasing population create major problem Bankrupt? Reconfigure Medicare? What Goes In = What Comes Out???

Potential Reconfigurations for Medicare Increase age limits Increase taxes and contributions Limit coverage Restrict benefits Increase coinsurance and deductibles Reduce payments

Aging and Demand For Services An increase of chronic disease Disappearance of nearby extended family Long-Term Care

Challenges for Primary Care  The “cult” of specialization  Too few generalists, too many specialists  The impact of managed care  Lack of government direction regarding PCPs  Changing medical models

Other Challenges… Advancing technology Shortage of nurses for hospitals Evolving public health threats Declining financial health of hospitals

Introduction to US Health Care Chapter 14 Public Health Policy Understanding the Role of Government in the U.S. Health Care System 14-25

Public Health Services Protection of the nation’s public health is a government responsibility. Public Health Agencies Three core functions are: Assessment Policy Development Assurance 14-26

The Department of Health & Human Services (DHHS) The DHHS and various federal agencies perform several public health functions. Data gathering and analysis, and surveillance and control: The CDC Conducting and sponsoring research: The NIH Providing programmatic assistance to state and local governments 14-27

State Health Agencies The state’s role in public health: Licensing health care professionals Inspecting and licensing health care facilities Collecting vital statistics 14-28

Local Health Agencies Food safety inspection Sanitation services Investigation and control of STDs Drinking water purification Most front-line public health services are provided locally

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