10 May Based on the readings discuss how the health s
Based on the readings discuss how the health system can motivate individuals to adopt behaviors that prevent most chronic diseases and illnesses.
Please make sure all responses are in your own words. Quality posts will utilize a source to support their statements. Please use APA format and be sure to cite the source if one is used.
Chapter 4
Medical Insurance and Access to Care
Processes For Thinking About the U.S. Health Care System
“In view of the Constitution, in the eye of the law, there is in this country no superior, dominant, ruling class of citizens. There is no caste here.”
— Justice John Marshall Harlan
Lecture Overview
Principles and Applications
The Three W’s of Medicaid Insurance: Who? What? Why?
Children’s Health Insurance Program
Why Is Government Insurance Economically Necessary?
Unaffordability of Advanced Medicine
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Medicaid insurance and access to medically necessary care. In Health care management and the law: Principles and applications (pp. 65-86). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
Principles and Applications
As millions of Americans gain health insurance as a result of the Affordable Care Act:
(1)Affordability of coverage remains a persistent problem for some
(2)Many technological innovations and health care initiations are focused on affluent communities and are accessible mainly to people with private health insurance.
(3)Health care in the United States costs more every year:
For every one in four adults who may be without health insurance for part or all of any given year, access to quality health care is simply not affordable
The Three W’s of Government Health Insurance: Who? What? Why?
Federal Share of Medicaid Spending
Medicaid is the government health insurance program for Americans with limited means and the severely disabled.
For states that expand Medicaid insurance through the Affordable Care Act, the federal government pays 100 to 90% of the costs
Regular match rate 60%
States that do not adopt the expansion will forgo substantial federal revenues:
Low income adults may fall into a coverage gap
Federal contribution varies based on state per capita householdincome relative to the national income average
The Three W’s of Government Health Insurance: Who? What? Why?
Who is Categorically Eligible for Medical Insurance?
Medicaid insurance is the principle safety net for:
Blind or severely disabled children and adults
Low income working families with children
Medicaid eligible with limited resources, who need assistance with filling gaps in their Medicare coverage
Uninsured pregnant women
Medicaid insurance does not provide coverage for everyone unless the state expanded traditional coverage
The Three W’s of Government Health Insurance: Who? What? Why?
Who is Categorically Eligible for Medical Insurance?
Disabled Medicare Beneficiaries:
1 out of 4 of the Medicaid insured are seriously disabled and receiving Medicare benefits
This population group accounts for more than 70% of the nation’s Medicaid insurance spending
Severely Disabled Children and Adults:
Medicaid insurance provides health insurance coverage for people with physical and mental disabilities and chronic illnesses.
Uninsured Pregnant Women:
Medicaid insurance provides access to prenatal care and neonatal intensive care for eligible women and their babies
The Three W’s of Government Health Insurance: Who? What? Why?
What Medicaid Insurance is Required?
There is no national consensus of the 3 W’s of Medicaid insurance:
Who is deserving of financial assistance?
What health care costs should be covered?
Why should the government be involved in the first place?
The demand for broader state accountability is a constant theme for Medicaid insurance as the 3 W’s are debated
The Three W’s of Government Health Insurance: Who? What? Why?
Coverage Issues
Controversies that remain unresolved include:
Rules for when someone may be eligible for Medicaid insurance coverage (3 month rule)
Entitlements for non citizens, if they are entitled at all, for taxpayer Medicaid insurance
Identification of what constitutes a life threatening medical event
Delivery system inequities between the uninsured/underinsured compared to those with comprehensive health insurance coverage plus the ability to pay out of pocket costs before any non life threateningtreatment is ever received
The Three W’s of Government Health Insurance: Who? What? Why?
Coverage Issues
Three Month Rule
Coverage may start 3 months prior to application for Medicaid insurance, if the individual would have been eligible during the retroactive period but:
was unaware of this opportunity, or
because the nature of their illness prevented them from seeking coverage
States seldom develop outreach programs to advise their residents of the benefits of Medicaid insurances
Coverage Issues
Lawful Permanent Residents
Most states have charity programs to provide medical assistance to residents who do not qualify for Medicaid but face extraordinary circumstances
MA Case legal residents 5 year rule
Coverage Issues
Definition Of Medically Needy:
Low income is only one test for Medicaid eligibility; assets and resources are also tested against established thresholds
The middle class is often covered when their private insurance is exhausted from medical situations:
Expenses from a catastrophic injury or illness that exceed private insurance
The medical treatments they elect are excluded from their coverage
Coverage Issues
Emergency Medical Services:
Emergency services must be life threatening to be covered by Medicaid insurance
Coverage Issues
Coverage Issues
Delivery System Inequities:
States increase Medicaid enrolments to qualify for more federal assistance rather than being given incentives to increase efficiency and higher quality
There are significant differences between states on measures of health care access, quality, costs, and outcomes
Coverage Issues
Coverage Incentives:
Accessibility
Accurate and comparable payment rates
Health outcomes, or whether coverage is actually improving health
Quality of health care
Should coverage be revoked if it turns out an individual experience was not life threatening?
Should there be a limit on the total amount of coverage Medicaid insurance will provide?
What should be considered life threatening?
Coverage Issues
State Waivers:
In states that chose to expand Medicaid insurance under the Affordable Care Act, all low income adults are now eligible for Medicaid health insurance that is subsidized by the federal government
A handful of states have received special permission, known as waivers, from federal regulators to take steps to improve their Medicaid insurance plans:
Indiana, Louisiana, North Carolina, Pennsylvania
Coverage Issues
Economics of the Medicaid Insured
With health insurance premiums rising more rapidly than the federal poverty level, the protection offered to the sickest and poorest Americans by Medicaid insurance has not kept pace with rising health insurance costs
Medicaid: Who? What? Why?
Access to Medically Necessary Care
While Medicaid insurance is an improvement over being uninsured, it often relegates Medicaid insured consumers to inferior health care:
Disparity in health care
Major reform of the U.S. health care system will require significant inter-governmental mandates for decades to come
Equal Access for El Paso, Inc. v. Hawkins
Equal access provision unenforceable
Paediatric Specialty Care, Inc. v. Arkansas Department of Human Services
Found an enforceable right
The Three W’s of Government Health Insurance: Who? What? Why?
Economic Inequities
Medicare/Medicaid Insured
Access problems faced by those who qualify for both Medicare and Medicaid insurance, generally referred to as being dual insured:
4 out of 10 physicians restrict access
30% of U.S. physicians refuse to accept new patients with Medicare/Medicaid insurance
Access for patients with Medicare/Medicaid insurance is most limited in urban areas
Most of the individuals who are dual insured face restrictions on access to the latest medical technologies
The Three W’s of Government Health Insurance: Who? What? Why?
Economic Inequities
Treatment of Serious Heart Conditions
The treatment of heart disease discloses clinical disparities that can only be attributable to the influence of insurance status:
80% of the hospitalizations for heart failure are patients with Medicare/Medicaid
Patients who are Medicaid insured face significantly more angina, poorer quality of life, and higher risks of hospitalizations after myocardial infarctions
Patients with Medicaid coverage are almost 50% more likely to die after coronary artery bypass surgery
The Three W’s of Government Health Insurance: Who? What? Why?
Economic Inequities
Diagnoses of Cancer
The probability of being diagnosed with late stage cancer is greater for the uninsured and Medicaid insured than it is for people with private coverage and health care
The Three W’s of Government Health Insurance: Who? What? Why?
Economic Inequities
Treatment of HIV/AIDS
The uninsured/underinsured with inadequate prescription plans complain about being denied access to the antiretroviral drugs that can prevent their immune systems from being weakened to the point of acquiring AIDS
Lack of early access is the difference between life and death from AIDS
Treatment is withheld for many uninsured Americans of limited means until it is too late for preventive care
Children’s Health Insurance Program
Created in 1997 to address the growing challenge of uninsured children:
Directed by the Centers for Medicare and Medicaid Services
Administered by the states, with broad federal guidelines, each state determines:
Administrative and operating procedures
Benefit packages
Design of its program
Eligibility groups
Payment levels for coverage
Should states be able to place limitations upon enrollment in Medicaid insurance, such as maintenance of a healthy weight, not smoking, or not abusing drugs?
Children’s Health Insurance Program (CHIP):Who is Targeted for CHIP?
CHIP is designed to provide health insurance to uninsured, low income children who:
Reside in a family with household income below 200% of the federal poverty level
Whose family has a household income 50% higher than the state’s Medicaid insurance eligibility threshold
Certain children cannot be covered under CHIP, including children who are:
Eligible for Medicaid coverage
Insured through an employer, an association, or an individual plan
Members of a family eligible for government sponsored health insurance based on employment with a public agency
Residing in an institution for those with mental illnesses
Waivers to use funds to cover adults with children exist
Children’s Health Insurance Program: Expansion of Medicaid Insurance to Higher Income Households
If a state elects to expand its Medicaid insurance using CHIP, the Medicaid insurance eligibility rules apply, including the inability to:
Enact lifetime caps
Enforce residency requirements
Establish time limits for eligibility
For states that opt for a separate child health program, certain other federal restrictions affecting Medicaid insurance eligibility are optional:
Choose to offer children one year of continuous eligibility
Enforce enrollment caps for eligible children
Have waiting lists for coverage of uninsured children
All states must establish a dual system of government insurance eligibility for children
Children’s Health Insurance Program
Limitation of Government Insurance Coverage
The federal government used to restrict the availability of CHIP to children who were not U.S. citizens
Since 2009, all children residing in the United States who meet need based requirements for participation are now eligible for coverage
Need Based Cost Sharing
States are permitted to impose different cost-sharing on CHIP
Some of the poorest insured families in America have unenforceable rights when their children are denied medical coverage
Children’s Health Insurance Program:
Middle Income Families
Families must be advised of their maximum annual cost sharing limit for each child; the state plan must describe the:
Consequences of not paying cost sharing charges
Disenrollment protections for families who cannot pay their cost sharing obligations
Methods used to determine cost sharing amounts
Should participation in CHIP be limited to children who are U.S. citizens?
Children’s Health Insurance Program
Low Income Families
Where children reside in households at or below 150% of the federal poverty line, states may not impose more than:
Nominal cost sharing fees
One cost sharing charge for all services delivered during a single office visit
One type of cost sharing for a medical service
What Health Insurance is Required for Uninsured Children?
States are required to offer medical services to eligible individuals and families that meet specified financial criteria
States cannot restrict Medicaid insurance coverage to focus on improving the health of their children
Why is Government Insurance Economically Necessary?
In a democratic society there is an economic need for the federal government to:
Seek expected utility maximization
Enhance state capacities for health insurance coverage
Help generate economic activity in the states
Maximize economic impacts on the U.S. health care system
Support a safety net
U.S. Health Care System and Safety Net
The guarantee of federal financing for Medicaid insurance enables states to respond to:
Aging population
Chaotic economic downturns
Emergencies and disasters
Increases in health care costs
Children’s Health Insurance Program
Generation of Economic Activity:
Additional tax revenues are derived from the health care jobs and household incomes generated
Economic impact of Medicaid funds is impacted because of the federal matching dollars
Health care jobs generate household income within the health care sector and throughout other sectors of the local economy due to the multiplier effect
Medicaid insurance funding to health providers supports health care jobs and household incomes
State spending on behalf of Medicaid insured consumers for health care pulls federal tax dollars into local economies
Children’s Health Insurance Program
Economic Impact on the Health Care System
Government payments to health providers, on behalf of the Medicaid insured, directly impact health providers by:
Creating household income
Promoting consumer purchases associated with the provision of health care
Supporting health care jobs
State Capacity for Health Insurance Coverage
The magnitude of economic impact from Medicaid insured consumers is dependent on:
Economic conditions of the state economy
Federal funding to the states for Medicaid insurance
Level of state funds available for Medicaid spending on health care
Unaffordability of Advanced Medicine
The United States has long prided itself in medical innovations, as the global leader in medical research and health care technology
One in four Americans cannot afford the costs required to meet their medically needed care
Prohibitive costs keep advanced medicine completely out of reach for many members of society, including the:
Low wage earners
Medicaid insured
Underinsured of limited means
Uninsured
This lack of access has been termed a health care crisis
,
Chapter 5 Medicare Insurance Reforms
Medicare Insurance Reforms
“Our current national health care system is simple: do not get sick.”
— Anonymous
Lecture Outline
Principles and Applications
Medicare Reform: Financing by Individuals or Society?
Complexity of Medicare Insurance
Structural Reform of Medicare Insurance
Reallocating Medical Treatments and Prevalence
Overhauling Medicare
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Medicare insurance reforms. In Health care management and the law: Principles and applications (pp. 87-97). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
Principles and Applications (1 of 2)
The Medicare program is the second largest social insurance program in the United States, behind Social Security, offering health insurance benefits to those eligible by virtue of their Social Security eligibility
Persons eligible for Medicare insurance include:
Individuals aged 65 and over
The severely disabled
Those with end stage renal disease
While the Medicare insured make up just 17% of the U.S. population, they account for most of the U.S. health care costs
The rise in treatment prevalence (common chronic diseases) accounts for most of the spending growth in health care costs
https://www.kff.org/medicare/issue-brief/the-facts-on-medicare-spending-and-financing /
The sickest 25% of the Medicare-insured spend 90% of the U.S. health care dollars with an average of:
At least one hospitalization yearly
$181,800 in health expenditures yearly
5 diagnosed medical conditions
10 prescriptions
12 physicians
The key to cutting costs lies with the physicians who treat these super-users:
At least two of their chronic medical conditions were preventable
Their care is not being coordinated by their multiple providers
They are being over-treated and mistreated (polypharmacy)
Principles and Applications (1 of 2)
Medicare Reform: Financing by Individuals or Society?
Medicare insurance must be changed if it is to be sustained
Its benefits package still closely resembles the standard package available in the mid 1960s:
70% of medicare enrollees have traditional indemnity insurance at a time when less than 2% of the insured have conventional insurance
Medicare payments are not intended to cover all the medical needs of enrollees, nor should society pay for all these expenses
Only 1 in 10 individuals over 65 relies solely on Medicare insurance; the rest have:
Medicaid insurance
Employer provided coverage
Supplementary health insurance in addition to Medicare
Indeminty Insurance Plans: different than policies offered bby HMOs, PPOs because it allowes you to obtain medical care wehre you choose providing compensation for a set portion of the cots. IT does not force you to choose a primary care doctor and you can self refer to specialisist. Very simliar to Fee-for service
Complexity of Medicare Insurance Part A: Hospital, Skilled Nursing, Home Health, and Hospice Care
Medicare Part A covers hospital insurance
Pays for almost ¼ of benefits spending:
Most of the Medicare insured do not pay premiums for this benefit, because they have already paid it through their payroll taxes
Part A does not cover custodial or long term nursing care, and consumers must meet certain eligibility criteria for home health and hospice care
The home health care benefit is available to individuals certified by their physicians as homebound
The Medicare hospice benefit is available only to individuals whose physicians have certified their expected mortality is less than six months away
Complexity of Medicare Insurance Part B: Physician, Outpatient, Home Health Care, and Preventive Services
Medicare Part B covers physician visits, outpatient visits, preventive services, and some home health visits
Most people pay a monthly premium for this insurance:
Medicaid insurance may subsidize premiums based on income eligibility, which varies by state
Services are provided on a medically necessary basis
No coinsurance or deductible is charged for an annual wellness visit or for preventive services
Complexity of Medicare Insurance Part C
Medicare Advantage
Medicare Part C refers to Medicare Advantage, where the federal government pays a fixed amount per member per month to private insurance companies that then coordinate and finance care
Consumers can select from a variety of private managed care plans and enroll in:
Health maintenance organizations
Preferred provider insurance
Private fee for service plans
Special needs plans
Medicare Advantage has doubled its enrollments in the past decade
Complexity of Medicare Insurance-Part C: Medicare Advantage Coverage
Medicare’s Special Needs Program
Restricted to dual eligible Medicare/Medicaid insurance consumers residing in long term care facilities
Serves about 1.2 million consumers
Complexity of Medicare Insurance-Part C: Medicare Advantage Coverage
Administrative Complexity of Medicare Advantage
With private/public sector complexity, the federal government has no way to monitor access, use, or performance for the over 165 million consumers enrolled in Medicare Part C
Medicare Advantage insurance plans are not required to:
Have Medicare review of services
Negotiate fees
Report quality measures
The increase in competition generated by higher payments to Medicare Advantage has not translated into better benefits for consumers
Complexity of Medicare Insurance Part D: Medicare Prescription Drug Coverage
Medicare Part D prescription plans generally have at least two economic objectives:
(1)Allow the health care system to improve the overall delivery of health care to the Medicare-insured
(2)Relieve the financial burden on those who have trouble affording prescription drugs
While the prescription drug program has value, it does not begin to address either of these economic objectives:
It shows how public perceptions, or misconceptions, can unduly influence decisions about health risks
Example of health policy based not on a rational response to health risks, but rather on misperceptions of risks
Complexity of Medicare Insurance – Part D: Medicare Prescription Drug Coverage (1 of 2)
The drug plan, while providing coverage at the lower and upper ends of expenditures, allows for a coverage gap in the middle:
Donut hole coverage
The drug benefit is not catastrophic coverage above a deductible, but rather:
75% coverage for a range of expenses, after a modest deductible (or, most of the donut), then
100% cost-sharing for beneficiaries (or, the donut hole with zero coverage), before
A return to 80% donut coverage (or, the rest of the donut)
Medicare Part D reduces coverage for people with high expenses to offer coverage for people with low expenses:
Provides most consumers with a return on their premium
Patient Assistance Programs
For enrollees covered by Medicare Part D, the medical products industry offers patient assistance programs that provide drugs outside the Part D benefit without any cost to the Medicare program
Most manufacturers have a data-sharing agreement with the federal government to help coordinate prescription use with plans providing Medicare prescription coverage
Medicare Part D benefit coverage has reduced the load on patient assistance programs, enabling the medical products industry to expand these programs to individuals with complex needs and high costs
Complexity of Medicare Insurance – Part D: Medicare Prescription Drug Coverage (2 of 2)
Complexity of Medicare Insurance – Supplemental Insurance Coverage
Medicare has high cost arrangements, no limit on out-of-pocket spending, and a coverage gap in the Part D prescription drug plan
Employer-sponsored health insurance, Medicaid insurance, and Medigap overlay each of the four types of Medicare
Help with cost-sharing requirements and benefit gaps
Medigap is a supplemental insurance offered through private insurers.
Takes care of medical expenses not covered by Medicare
Most of the Medicare-insured have some sort of supplemental coverage
Structural Reform of Medicare Insurance (1 of 2)
It is important to gather more evidence about the implications of either paying less to Medicare Advantage or other changes in entitlement to make the Medicare system more fiscally responsible
Little attention is being drawn to the:
$65 trillion the United States needs to make Medicare whole
$1 billion that private insurers get in profit subsidies from Medicare Advantage plans each year
$1 trillion in unfunded health care obligations for health care retirees
Discussion generally centers on increasing payroll taxes or the premiums for Medicare insurance
How to control the growth of Medicare?
Structural Reform of Medicare Insurance (2 of 2)
United States v. Lahey Clinic Hospital, Inc.
Demonstrates the problems that may arise under single-payer systems without competition
Physicians could not compete for laboratory services and receive lower rates
Obtaining more revenue for the Medicare program does not solve the issue of long-term sustainability until unnecessary spending like the Lahey case is controlled
Medicare puts a price tag on consumer’s health, perhaps even their lives
Reallocating Medical Treatments and Prevalence
Given the higher costs of Medicare Advantage, with no discernible improvement in the quality of its managed care, there may be many opportunities to cut its services, with little minimal adverse impact on consumers
The money saved could then be allocated where it may provide more efficient benefits:
Advertising expenditures are expanding but better quality care does not come from advertising.
The rise in treatment preference, rather than rising treatment costs, accounts for most of the spending growth
“This person’s life expectancy is only so many years, so this procedure is not worth the cost”
Overhauling Medicare
There is a general consensus on several overhauls of the Medicare system:
Increase payroll taxes and premiums for medicare insurance to those who can afford to pay more
Mandate that profit subsidies from Medicare Advantage be returned to consumers in the form of reduced premiums or additional benefits
Monitor quality use and performance for all the Medicare-insured
Require more competitive bidding for medical services reimbursed by Medicare insurance
Overhauling Medicine
Everyone pays for hospitalization insurance through payroll taxes, but physician payments for prescription drug benefits are voluntary:
Perhaps those who are better off should pay higher premiums
Medicare is an inadequate health insurance plan in the sense that it does not protect against long hospital stays or catastrophic expenses
The least likely to purchase supplemental Medicare coverage are financially distressed consumers with complex needs
Management and Law Issues
Why is it important to provide health care cov
