florida blue health care policy overview: agent ceu course
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TRANSCRIPT
Health Care Policy in a Health Care Policy in a NutshellNutshell
Health Care Policy in a Health Care Policy in a NutshellNutshell
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Welcome!Welcome!Welcome!Welcome!
Our one-hour session today will cover Health Care Policy, including:
Background and History of Health Policy
Cost, Access, and Quality
Proposed Solutions2
Background and History of Background and History of Health PolicyHealth PolicyBackground and History of Background and History of Health PolicyHealth Policy
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History of Health System and History of Health System and PolicyPolicyHistory of Health System and History of Health System and PolicyPolicy
Transformation of hospitals and the role of physicians
The role of government
• Presidents Teddy Roosevelt, Truman, Clinton and Obama
• Medicare and Medicaid
• HMO Act of 1973 - Nixon
• 1997-SCHIP
• 2010 Health Care Reform4
History of Health System and History of Health System and PolicyPolicyHistory of Health System and History of Health System and PolicyPolicy
Employers
World War II
Health Insurers
1847-First comprehensive group policy offered by Massachusetts Health Insurance of Boston.
1929 First Blue Cross Plan
Managed Care – Mid-1990’s
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Who are the Stakeholders?Who are the Stakeholders?Who are the Stakeholders?Who are the Stakeholders?
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Who Pays What?Who Pays What?Who Pays What?Who Pays What?
Hospital Payment/Cost Ratios
Private Payers - 110% to 130%
Medicare – 92% - 102%
Medicaid – 80% - 95%
Private payers pay higher reimbursement rates to physiciansSource: Feldstein
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Health Care System DynamicsHealth Care System DynamicsHealth Care System DynamicsHealth Care System Dynamics
DRG payment system
Managed Care
• Provider Response• Consumer Response
Accountable Care Organizations, Shared Savings and Patient Centered Medical Homes
• Provider Response• Payer Response
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The Iron Triangle of Health Care The Iron Triangle of Health Care PolicyPolicyThe Iron Triangle of Health Care The Iron Triangle of Health Care PolicyPolicy
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Health Care CostHealth Care CostHealth Care CostHealth Care Cost10
2012 National 2012 National Health Care Expenditure DataHealth Care Expenditure Data2012 National 2012 National Health Care Expenditure DataHealth Care Expenditure Data
Total Health Care Expenditures $2.823 Trillion
Hospital Care $873.1 Billion (31%)
Physician $542.9 Billion (19.2%)
Prescription Drugs $290.2 Billion (10.3%)
Source: CMS https://www.cms.gov/NationalHealthExpendData/downloads/tables.pdf 11
Total Health Expenditure per Total Health Expenditure per Capita, Capita, U.S. and Selected CountriesU.S. and Selected Countries
Total Health Expenditure per Total Health Expenditure per Capita, Capita, U.S. and Selected CountriesU.S. and Selected Countries
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What are the cost drivers?What are the cost drivers?What are the cost drivers?What are the cost drivers?
Medical Technology
Payment structure (fee for service)
Fraud, waste and abuse
Tax incentives
Tort liability
Lifestyle13
Health Care Costs and FloridaHealth Care Costs and FloridaHealth Care Costs and FloridaHealth Care Costs and Florida
• $132 billion in state health expenditures in 2009
• $23 billion on Medicaid (including federal share)
• Medicaid Reform
• Medicaid Expansion
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Medical Treatment vs. Medical Treatment vs. PreventionPreventionMedical Treatment vs. Medical Treatment vs. PreventionPrevention
Intervention Number of Lives Saved per 1,000 Additional
Participants
Cost per Life Saved
NICU’s 2.8 $4,778Prenatal Care 4.5 $39
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Health Care AccessHealth Care AccessHealth Care AccessHealth Care Access16
Two Major FactorsTwo Major FactorsTwo Major FactorsTwo Major Factors
Ability to pay
Labor supply versus demand
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Ability to PayAbility to PayAbility to PayAbility to Pay
Approximately 16.3% of Americans are uninsured.
Approximately 21% of Floridians are uninsured.
Education, jobs and health insurance
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Expanding Coverage Through the Expanding Coverage Through the ACA?ACA?Expanding Coverage Through the Expanding Coverage Through the ACA?ACA?
Medicaid and Subsidies
Polarized political climate
State and federal budget concerns
Lingering legal issue regarding federal exchanges
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Supply of Primary Care Supply of Primary Care PhysiciansPhysiciansSupply of Primary Care Supply of Primary Care PhysiciansPhysicians
2007 survey showed that only 7% of medical students planned to go into primary care.
In Florida, 37% of non-federal physicians practice primary care, compared to 39% throughout the United States.
15.1% of Floridians are underserved compared to 11.4% nationwide.
Source: Kaiser Family Foundation 20
Outlook for Physician DemandOutlook for Physician DemandOutlook for Physician DemandOutlook for Physician Demand
Population growth
Aging population
Per capita income increasing, so use of physicians are increasing
More technology
Increased use of lab tests and imaging services
Calls for more medical schools 21
Outlook for Physician SupplyOutlook for Physician SupplyOutlook for Physician SupplyOutlook for Physician Supply
Decreased work effort expected
Advanced Non-Physician Practitioners
Aging physicians: 61% are 45 or older
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QUALITYQUALITYQUALITYQUALITY
Health Care QualityHealth Care QualityHealth Care QualityHealth Care Quality
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Definition of QualityDefinition of QualityDefinition of QualityDefinition of Quality
“The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”
Source: IOM
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Quality: Quality: Who measures it and Who measures it and how?how?Quality: Quality: Who measures it and Who measures it and how?how?
Service quality
Clinical quality
• Process
• Outcomes25
OpportunitiesOpportunitiesOpportunitiesOpportunities
Americans receive evidence based care 55% of the time
Medical errors cost the health care system $17.1 billion nationally
Death rates from cancer, heart disease and stroke are higher among ethnic minorities in Florida
Defensive medicine
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Health Care ProposalsHealth Care ProposalsHealth Care ProposalsHealth Care Proposals27
ThemesThemesThemesThemes
Cover the uninsured
Improve quality while increasing efficiency within the delivery system
Wellness and prevention
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High Level ACA IssuesHigh Level ACA IssuesHigh Level ACA IssuesHigh Level ACA Issues
Expansion of coverage through Medicaid and subsidies
Health insurance market reforms and exchanges
Quality demonstration projects
Public health initiatives
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ProposalsProposalsProposalsProposals
Universal coverage (various varieties)
Aggressive outreach to those that are currently eligible for public programs but are not enrolled
Sustainable public programs
Bolster primary care workforce 30
ProposalsProposalsProposalsProposals
Robust health information network
Comparative effectiveness research
Collaboration among patients, providers and payers
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ProposalsProposalsProposalsProposals
Allow for creative and iteratively innovative approaches to the coordination and delivery of services that focuses on the patient and increases quality and efficiency
Efforts to address health care disparities and health literacy
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ProposalsProposalsProposalsProposals
Maintaining healthy competition within the delivery system
Maximize efforts to reduce fraud, waste and abuse in the health care system
• Tort reform
• Greater investment in law enforcement
• Use HIT to eliminate duplication and other waste
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ProposalsProposalsProposalsProposals
Adequately fund safety net programs to expand coverage to vulnerable populations, that is fiscally sustainable
Encourage worksite wellness programs
Strategically craft public health initiatives that will have the largest impact
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Grow, Pay or Cut? Economic Grow, Pay or Cut? Economic ConstraintsConstraintsGrow, Pay or Cut? Economic Grow, Pay or Cut? Economic ConstraintsConstraints
Medicare
Gross Domestic Product
Federal Taxes
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Unauthorized EntitiesUnauthorized EntitiesUnauthorized EntitiesUnauthorized Entities
An entity that is required to be licensed or registered with the Florida Office of Insurance Regulation but is operating without the proper authorization is identified as an unauthorized insurer. All persons have the responsibility of conducting reasonable research to ensure they are not writing policies or placing business with an unauthorized insurer.
Any person who, directly or indirectly, aids or represents an unauthorized insurer can lose their licenses or face other disciplinary sanctions. Please see section 626.901, Florida Statutes, to read the laws. Lack of careful screening can result in significant financial loss to Florida consumers due to unpaid claims and/or theft of premiums. Under Florida law, a person can be charged with a third-degree felony and also held liable for any unpaid claims and refund of premiums when representing an unauthorized insurer. It is the person’s responsibility to give fair and accurate information regarding the companies they represent.
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