HSCI 678 Intro to US Healthcare System

Future Directions in the US Health Services Delivery System

Chapter 21

Tracey Lynn Koehlmoos, PhD, MHA

Cost-Quality-Access

ACCESS

QUALITY COST

What changes?

Who will be effected?

Why?

Financing Changes

• Economic Support Component—changes here directly impact health service delivery

• Public Financing—Medicare and Medicaid– Gradual climb to being #1 payer– 2016, Medicaid Part A, expenditures > revenue– 2029, Part A Trust Fund, bankruptcy!– Part B, 75% from general federal funds, growing– Part D, will it boost Medicare expenditures?

More Financial Changes

• Increased out-of-pocket

• Higher deductibles, increased co-pay

• Backlash against Managed Care

• Consumers will pay more

• Reductions in health insurance benefits

• Quest for new payment mechanism between FFS and capitation

Delivery System Changes

• The pendulum has swung toward increasing capacity (ex. ER services)

• MCOs changes due to cost inefficiency– Curbing prior authorization process– Reevaluating gatekeeper functions

Changes in Access

• Need to measure the full impact of: – HIPAA (1996)—small businesses may still

find offering health insurance too costly – MHPA (1996)—Mental health coverage is

NOT equal to physical health coverage—no replacement act since 2001

– SCHIP (1997)—Slow enrollment in some states

• Proportion of uninsured: STILL 15-20%

Changes in Quality

• More focus, any improvement?

• AHRQ: evidence-based health services

• QIOs (Quality Improvement Orgs): CMS switch from focusing on blame to focusing on performance improvement

• IOM: adverse events, avoidable death or disability

• Dismantling Managed Care: removes a platform of measuring quality

Changes in Cost?

• Do you really need to ask!

• March 2006: Access to the accurate cost of procedures – Through companies like HealthGrade, Inc.– Allows for individuals to compare prices and

encourages health savings accounts

Why are changes happening?

• Provider and consumer backlash against managed care

• Population demographics

• Advent of new technologies

• Likely to see incremental rather than monumental change

Effects of Change on Consumers

• Insured: – Involuntary changes of insurance plan,

providers– Higher cost sharing, decreased dependent

coverage

• UnInsured:– Still no access to primary care– Less uncompensated care– Rigorous screening at ERs.

Effects of Change on Providers

• Doctor as frustrated businessman

• Switch to outpatient services

• Loss of autonomy

• Advent of the Hospitalist

• Provider payment decreases (Medicare and Medicaid)

• Rising malpractice insurance costs

Effect of Changes on Payers

• Employers and Medicare/Medicaid

• Frustrated by higher costs

• Frustrated by burgeoning delivery system

• More likely to use cost sharing methods

Effects of Change on Health Insurers

• Are they really the villains?

• Double digit increases in premiums—to cover the cost of paying for services

• Private companies looking to reduce risk

• Move to high deductible plans

• Move toward reduce benefits packages

Future Direction

• The only constant is CHANGE

• No viable solution to fix the problem of the uninsured

• Medicare Part D, what impact?

• Increased cost sharing, likely

Conclusion

• How much do we value choice?• Is access to basic health services a right?• To what extent does controlling access

and containing expenditures jeopardize the provision of high quality service?

• There are no quick answers—but as health service leaders we must always be aware of the changing healthcare environment.