1. HSCI 678 Intro to US Health Services System Health Insurance: Major Finance Mechanism Chapter 6 Dr. Tracey Lynn Koehlmoos

2. Chapter Overview Insurance Concepts Evolution of Health Insurance Private Health Insurance Public Health Insurance Pending Policy Reforms This chapter will not cover managed care

3. General Concept Insurance protects against infrequent, large loss by establishing contractual relations between the insured and the insurance provider and spreading the risk across a larger population.

4. General Risk Assessment Underwriting Process-actuarial risk Experience Rating Cherry Picking/Cream Skimming Adverse Selection Redlining Insurers goal: premium $ received > benefit $ paid

5. Specific Health Concepts Early days: –Linked to Employment –Hospitalization Only (1:13 among non-elderly) Conceptual Shift –Expanded scope of interactions –Non-random, non catastrophic events –Commercial v. social purpose

6. Risk Assessment 35% of insured—no claims 5% of insured = majority of claims Most insurers require medical screening Pre-existing conditions –Excluded –HIPAA (1996)

7. Direct Risk Adjustment Medical Underwriting –Tier rating—by member and industry –Durational rating—Low $ to start, increases over time Redlining –Excludes individuals or groups based on perceived hazards, life-style or claims history

8. Indirect Risk Adjustment Co-payments Limited Benefits Packages (procedures/pharmaceuticals) Caps/Ceilings Waiting period for effectiveness Results in inequitable access across the US

9. Growth of Commercial Health Insurance Provider-Organized Plans—dominant before WWII Post-WWII: Growing Non-for Profit Hospitals, more plans based on employment groups 1947 Taft-Hartley Act: Health benefits as a condition of employment for which labor was entitled to negotiate

10. Availability in Small Businesses Smaller businesses <100 employees 50% of US labor firms Nature of business too high risk Unaffordable premiums—cannot spread risk Part-time work force One claim could increase all premiums 10 to 40% higher cost to small v. large business

11. Retiree Health Insurance Larger companies offer this as a benefit Hard to capture this group as data Jeopardy of benefits due to shake-ups in the mid-1980’s Medicare eligible—Medicare 2 nd payor Employers seek higher cost share Medicare Part D; Patient’s Bill of Rights

12. Self-Funded Health Insurance Large group of employees Eliminates need for insurance company ERISA exemptions Pay only what is used Can negotiate rates Insurance companies can be hired to bear excessive financial risk Third Party Administrator can handle admin.

13. The Cost of Doing Business Health Insurance is a major expense Premium growth rates—on the rise, again $4,692 per employee & family per year $2,088 per employee per year 75% of business health expenditures are on health insurance premiums 16% Medicare Contributions 8% Workman’s Compensation

14. Cost Containment Measures Cost Sharing/Co-payments Limiting Scope of Benefits Caps on Insurance Expenditures Controls on Utilization –Prior Authorization –Second opinions –Pre-certification (nursing home stay)

15. ERISA Employee Retirement Income and Security Act of 1974 Allows large employers to self-insurer Response to concerns on pension mismanagement Protects health services benefits packages

16. HIPAA Established requirements for carriers at the individual, small and large group markets Portability from group to individual plan Limits pre-existing condition waiting periods Also, state reforms in the early 1990’s

17. HIPPA Health Insurance Portability and Accountability Act of 1996 Allows employees to “carry” insurance to the next job without a waiting period Allows employees in small companies to bring in previous insurance Addresses confidentiality issues

18. Summary of Private Insurance Covers 2/3 of US population Mostly as employee benefit, large group New laws and regulations to protect the benefits of the insured Ineligible people—may use individual policies

19. Public Health Insurance Tricare Medicare Medicaid State insurance programs for the uninsurable State Child Health Insurance Programs

20. Tricare Military dependents and retirees Supplemental to Military Health Service System 8.4 million beneficiaries Outside of the military system, Tricare functions as an HMO with contracts awarded to regional civilian companies.

21. Medicare Social Security Act of 1965 Originally only for >65 years of age –Currently: 87% of beneficiaries 1972: End Stage Renal Disease (ESRD) 1973: Any age, Medicare disability –Currently: 13% of beneficiaries

22. Do you know your ABCD’s? Part A: Hospital Insurance (HI) –SNF, HH, Hospice –Deductible $840 per benefit period –Financed by Fed Trust Fund (payroll deduction, employer contributions) Part B: –Supplemental Medical Insurance (SMI) –Physicians, tests, outpatient services –Monthly premiums 75% & by Fed Trust Fund

23. More Medicare ABCD’s… Part C: Medicare + Choice, 1997 –Managed Care with mixed results –Patients were slow to sign up –Providers found it costly Part D: Prescription drug plans –New and confusing –Threats to Medicaid/Medicare –Slow patient sign up

24. Medicaid Social Security Act of 1965 State and Federal Program 50/50 No or Low co-pay or deductibles State offerings vary All include: Inpatient, outpatient, x-ray, HH, preventive services for children, family planning Some: Podiatrist, Dentist, Physical therapy, case management, eyeglasses

25. Medicaid Eligibility Eligibility varies—almost all “Low Income” Pregnant woman Infants, children < 6 Elderly, blind, disabled, poor Medicare Special groups who qualify because of the disease (HIV/AIDS, NBCCEDP)

26. Who is on Medicaid?

27. Where does the money go?

28. Other State Run Programs Medically Indigent Programs State Sponsored Health Insurance Programs for the Uninsurable State Children’s Health Insurance Program (SCHIPs)—BBA 1997

29. Other types of insurance Workers’ Compensation Insurance Viatical Settlements Health Ins Purchasing Cooperatives

30. Summary 70% of US and almost all elderly have health insurance Medicaid covers 10% of US population 20% of US population NO insurance Cost of premiums continue to rise Employer sponsorship remains link No basic set of benefits in the US