1. Describe the development of health insurance and, in general, what kinds of benefits were covered in the early 1940s.
1798: origin of health insurance changes when government hospitals were established in some coastal cities to provide care for merchant seamen
19th century: a form of insurance can be obtained though trade unions, fraternal organization, or through employer.
1914: workers’ compensation or compulsory sickness insurance programs appeared
1917: several states considered health insurance bills
1920s: prepaid health programs were first introduced
1929: Great Depression. Public school teachers enrolled in a plan covering hospital costs. Blue Cross established to cover hospital costs
1939: Blue Shield created to cover physician fees. These insurance programs as third-party payment system began replacing tradition of patient paying practitioner directly
2. Define an HMO/MCO
HMO: Health Maintenance Organization. Provided comprehensive medical care for a fixed fee for its enrollees. Physicians are paid a set amount of money to provide agreed upon services whether or not needed by patients
MCO: Managed Care Organization. New name for HMO. Systems, programs or actions aimed at controlling health care utilization, costs and promoting quality improvement. Has more emphasis on medical outcomes and more provider risk assumption
3. What was the objective of Hill-Burton?
Provided considerable grant monies for the renovation and expansion of existing hospitals as well as the construction of new ones, primarily in undeserved inner city and rural areas. Promoted concept of a hospital for every community.
4. Describe the primary factors that lead to a more healthy life
- Changes in standard of living or lifestyle, including improvement in personal hygiene, diet, nutrition, and housing
- Advances in public health measures, such as improved sanitation, water supply and delivery, and refuse collection and waste removal
- Progress in medical practice, including therapeutic interventions in the treatment of patients
5. What is the most rapidly growing age group in the US and list the major reasons for this occurrence?
85 years and older. Several years of effective public health policy, including improvements in sanitation and nutrition and the development of immunization. Advances in technology have helped to find new treatments and cures (immunization and antibiotics) for many cute forms of illness. Current concerns are focused on management of chronic conditions. “Baby-boomers” are aging.
6. What are the leading causes of death in the United States?
A new report from the Centers for Disease Control and Prevention (CDC), National
Center for Health Statistics looks at the latest trends in mortality for 2001, the most recent
year for final data. The report is based on data from death records filed by State vital
statistics offices and reported to CDC’s National Center for Health Statistics through the
National Vital Statistics System. According to 2001 data, the 10 leading causes of death
in the United States are:
1. Heart disease
2. Cancer
3. Stroke
4. Chronic lower respiratory disease
5. Accidents
6. Diabetes
7. Pneumonia/flu
8. Alzheimer's disease
9. Kidney disease
10. Suicide
7. What is the definition of health?
Health is a state of complete physical, mental and social well-being and not merely the
absence of disease or infirmity. The correct bibliographic citation for the definition is:
Preamble to the Constitution of the World Health Organization as adopted by the
International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946
by the representatives of 61 States (Official Records of the World Health Organization,
no. 2, p. 100) and entered into force on 7 April 1948. The definition has not been amended since 1948.
8. Summarize health and mortality trends, which have occurred this century?
- Increases in life expectancy (49.2 years in 1900 to 76.9 years in 2000)
- Declines in infant mortality (47 infants per 1000 live births in 1940 to 6.8 infants per
live births in 2000)
- Causes of death shifting from acute, infectious diseases to chronic, non-infectious
Illnesses
9. Describe the government’s role in health and health care over the past 200 years.
Professor Stranberg himself answered this question in class (see his Power Points). The
federal government’s role was minimal in late 1700’s; it was responsible for the military
health care but could not quarantine seaports, for instance. In 1796 a debate began in the
courts as to which government (federal or state) should be responsible for public health.
The debate ended in 1893 in court ruling, allowing the federal government to move
slowly into areas neglected by the market.
The 1930’s focused attention on public health issues that the states could not handle. The
Social Security Act of 1935 (originally named “Social Health Insurance Act”) was born
as a result, providing money for child health and public health programs. The Social
Security Act also increased the involvement of non-health care professionals in decision
making.
In 1946 the Hill-Burton Act was passed, funding 4,000 health buildings and mandating
free hospital care for 20 years. Medicare (and Medicaid) in 1965 and PSRO in 1972 were
amended to the Social Security Act. In 1973 the HMO Act was passed as a cost
management utility.
10. Describe cost shifting.
A phenomenon occurring in the United States health care system in which providers are
reimbursed for their costs and subsequently raise their prices to other payers in an effort
to recoup unreimbursed costs. In the past, low reimbursement rates from government
health care programs often led providers to raise prices for medical care to private
insurance carries.
- Discuss the fundamental differences between the focus of the regulatory and market approach to controlling health care costs. (slide 99)
- Market Approach: Solely utilize capitalistic competing mechanisms of delivery w/o governmental control or intervention.
- Regulatory Approach: Implement government controls which will utilize taxpayer funding to keep health care costs low as well as covering more citizens.
- How is health care financed? (handout for slide 107 pg. 9)
- As of 2002: Public funding 44.2% and private funding 55.8%. Examples of public funding: Medicare, Medicaid and Oregon Health Plan. Examples of private funding: employer sponsored medical benefits packages and individually purchased plans.
- Describe the Medicare physician payment system, resource based relative value system (RBRVS) and discuss its implications. (slide 141)
- RBRVS was established by Medicare and sets up a system of the following: 1. Fee schedules for medical office visits (costs for procedures are predetermined) 2. This provides risk to be assumed by the docs via capitation so they have a vested interest in providing the highest quality care or they lose money. The RBRVS system is now commonly used by insurance companies to cut long term costs. The ideal implications would be to improve patient outcomes and decrease health care costs at the same time.
- Discuss the pros and cons of cost containment from the vantage point of “Has cost containment gone too far?” (couldn’t find a particular slide #)
- Pros: Lower expenses for patients, lower expenses for employers, less money and resources wasted on unnecessary procedures and expenses that don’t actually improve patient outcomes.
- Cons: Too many people that are in charge of making the cuts to contain the costs are not health care professionals, so they might not foresee various consequences of the cuts. If the cost containment is done too quickly and haphazardly solely to improve the bottom line, then the patients lose in the short term and in the long term. Finally, cost containment can easily fall in the trap of looking at solutions to health care problems only in terms of dollar signs, losing perspective on empathy, emotion and quality control.
15. Describe the uninsured population and discuss the implications of this problem. (no slide found)
- Typically, the unemployed and their families make up a large population of the uninsured. However, there is also a large group of people now that are employed but their employer will only cover them and not their dependents. Many of these people don’t earn enough to pay all the bills and cover their children too.
- The implications are major and pretty obvious. Lack of proper health care for the uninsured makes them less likely to be able to work and be an integral part of the community now and really increases the odds that they won’t be able to work and be as energetic in the community later. Dealing with health issues in a preventative maintenance fashion has been shown to be much cheaper than ignoring warning signs of problems that become chronic, debilitating and very costly to the individual and the community in the future.
16. Discuss the problem and the implications of uncompensated hospital care
Uncompensated hospital care discourages many for profit and even most not-for-profit hospitals from providing healthcare to indigent patients. This places greater strain and responsibility on public hospitals, which at this time are becoming less and less prevalent throughout the United States, due to the competitive market of the healthcare field. With the growth of for-profit and not-for-profit hospitals and the decline and closure of public hospitals, in the near future, uncompensated hospital care could potentially wipe out all avenues of healthcare to the indigent population; leaving a substantial subgroup of our population not only lacking healthcare insurance, but also lacking the means to access any kind of care.
17. Discuss the importance and meaning of health care outcomes
Health care outcomes are not purely considered to be clinical endpoints (such as “peak-flow-rate” in an asthma patient). Outcome can also be referred to in terms of the patients quality of life (for example: Quality-adjusted life years (QALY)) or as cost of treatment verses benefit gained to name of few. Measuring outcomes has significant advantages to both the supplying parties (hospitals, clinics, physicians etc.) and the receiving party (the individual patients and groups of patients). For both parties, outcomes help to determination of the lowest cost therapies offering the highest reward. This helps to 1.) foster medical innovation, due to the incentive nature 2.) it leads to decreased healthcare costs 3.) it leads to increased productivity in the work force for those patients that received the improved care. In addition, measuring healthcare outcomes helps to identify areas of practice that are harmful and should be either discontinued or altered, further increasing the benefit gained by patients and further decreasing healthcare costs, but eliminating wasteful and harmful practices.
18. Discuss why variations exist in physician practice patterns for similar patients
Three main factors for why variations exist
- Physician preference (includes differences in physicians training, opinions, motives, values and biases)
- Patient characteristics (such as age, sex and severity of illness)
- Patient preferences (due to education, geographical location, etc.)
Since the book did not provide any information regarding this question I went in search of it and came across an article that I feel addresses this question in depth. If you are interested in reading it here is the site:
19. Discuss the implications of an aging society accessing and being served by our existing health care system. Discuss the implications of the Aids Epidemic.
Under the current structure of our health care system, we (healthcare field and healthcare workers) are not fully prepared for the undertaking associated with caring for the ever increasing aging population. Shortages in healthcare workers and healthcare professionals and lack of infrastructure, such as assisted living facilities all contribute to our inability to provide high quality care to our aging population. In addition, cost plays a major role. With more and more individuals reaching the age at which they are able to access Medicaid benefits, further strain will be placed on the government, leading to greater federal spending with no resolutions in sight.
The Aids epidemic places great strain on our healthcare field and on society in general. Currently and into the future, Aids will have “a profound affect on future rates of infant, child and maternal mortality” (leading to a future decline in our potential workforce, which could also exaggerate the healthcare shortages already in existence); “life expectance; and economic growth.”
20. Discuss the health care crisis
There is a long laundry list that is currently contributing to the healthcare crisis, but of greatest importance is, 1.) the ever increasing aging population, 2.) the rising number of individuals lacking health insurance or being under covered (along with an outdated Medicare program) and the rising costs associated with healthcare, with less return.
21. Development of Kaiser-Permanente:
Book:
Kaiser-Permanente came into exsistance in the 1930’s. Kaiser offered medical coverage to employees of Henry F. Kaiser during the construction of the Grand Coulee Dam. The program expanded to cover employees in his steel mills and shipyards and eventually to the general public on the west cost.
Slide#57:
How did HMOs start?
- Grand Coulee Dam Project-1930s
- Kaiser Construction Company needed health care for workers
- Spun off as a separate company after W.W.II
- Group Health Coop-mid 1940s Seattle
- A true consumer CO-op
22. What is the purpose of the HMO Act of 1973?
Book:
In the post-World War II social climate several attempts by congress to create a national health insurance program failed, largely due to the AMA. The AMA favored a third-party payment system in which the public would pay insurance companies and the companies in turn would pay hospital and doctor fees. The creation of Medicare (1965) which covered hospital insurance and doctor visits for people over 65, and Medicaid cemented the role of the third-party system in health care delivery.
The HMO Act of 1973 was congress attempt to create a broad health insurance coverage program. This act required every employer with more than 25 employees who offered a health plan to include at least one HMO plan providing comprehensive medical care for a fixed fee.
Slides#51:
(2)HMO Act of 1973
- Signed into law by Richard Nixon-was his cost Mgt. agenda
- Provided start up money to small HMOs
- $364 million provided by feds
- Regence HMO started this way via Captiol Health Care in Salem mid 1970s
- Purpose was to stimulate development of cost management
23. The health care system is composed, in general, of providers, purchasers and regulators. Describe each and their roles.
The health care system has 3 components; providers, purchasers, and regulators. Providers include people such as doctors and pharmacists as well as organizations. Hospitals, clinics, MCOs, PPOs, and PBMs are all different types of health care organizations. In general the role of providers is to finance and/or deliver health care services to specific populations usually through the creation of purchasing alliances. Besides providing the usual services hospitals are also centers of teaching and research for the practice of medicine.
The second component of the heath care system is purchasers, which include:
- Self Insured Employers-private sector
- Are exempt from state insurance commission oversight
- Government-Medicare/Medicaid
- Insurance Companies/Agents
- Insurance Brokers/Insurance Consultants
- Agent is the representative of Insurance Company whereas broker is the representative of the consumer or policy holder. An agent is licensed to work for only one company, whereas a broker can deal with more than one company.
- Business Coalitions on Health
Business coalitions on health: their activities and impact.
Jt Comm J Qual Improv. 1994 Jul;20(7):376-80
Cronin C.
Managed Health Care Association, Washington, DC 20005.
BACKGROUND: Business coalitions on health-generally nonprofit, community-based membership organizations primarily composed of local employers-attempt to manage the cost and quality of health care delivery. They are also active in other areas, including member education, data collection, and selective contracting. ISSUES: With reference to projects related to public accountability for hospital quality of care, coalitions have been involved in legislative support of state public databases, efforts to develop severity-adjusted information on hospital quality, group purchasing from selected hospitals based on cost and quality-an activity conducted in more than 20 locales, and consumer education. CONCLUSIONS: With health care reform, coalitions will need to shift from looking solely at individual physicians and hospitals to looking at them in the context of managed care. Balancing the tension between continuous quality improvement activities and public accountability will also be an important issue for coalitions. The future of coalitions after health care reform is uncertain, with scenarios ranging from their demise to their expansion as active purchasing coalitions or their assumption of new roles and activities. Whatever the future viability and focus of health care coalitions, they have effectively served as change agents in their communities.
PMID: 7951767 [PubMed - indexed for MEDLINE]
Regulators make up the third and final component of the healthcare system.
- Board of Pharmacy
- Regulation of pharmaceutical practice and professionals occurs mostly at the state level. Board of Pharmacy is usually made up of pharmacists and several public members. Regulation of professionals by professionals.
- FDA
- Functions include (1) the premarketing clearance of all new drug products on the basis of purity, safety, and effectiveness (2) regulation of all labeling, including advertising of prescription drug products (3) regulation of manufacturing along the guidelines of good manufacturing practices and instituting recalls of unacceptable products (4) regulation of bioequivalence standards (5) conducting postmarketing surveillance.
- DEA
- Enforce drug laws
- Elected State and Federal Legislators
- Pass laws, focus on OARs division 41
24.