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Managed Care & Health Care Reform
Cost of Health Care
$1.03 trillion in 1997
15% of GNP
4%-5% annual increase in health care spending
Division of Health Care Costs
Hospital care 34%
Physician care 20%– Together make up 54% of health care costs
Home Health care 3%
Public Health 3%
Research 3%
The Uninsured
43.6 million in 2002
15.2% of population
1 in 7 uninsured
Characteristics of the Uninsured
Born in America 12.8%
Naturalized citizen 17.5%
Not a citizen 43.3%
Blacks 16.9%
Hispanic 23.4%
White 54.3%
Other 5.4%
Household Income for Uninsured
Under $25,000 23.5%
$25,000 - $49,000 19.3 %
$50,000 – 74,999 11.8%
$75,000 & over 8.2%
Education of Uninsured
No high school 28.0%
High school graduate 18.8%
Some college, no degree 15.0%
Associate degree 12.1%
Bachelor’s degree & higher 8.4%
Employment
Private sector 60.2%
Self-employed 12.7%
Public sector 5.5%
Unemployed 21.6%
Health of Uninsured
No use of preventive health care
Seek treatment when illness more advanced
Receive inadequate care
Higher morbidity and mortality rates
Response of US Government to Health Care Crisis
Retrospective payment system
Reimbursement per unit of service
Prospective payment system
Reimbursement based on average value of service
Managed Care Plans
Characteristics
Prepaid health insurance plans
Health care providers accept lower payments
Gatekeepers to health care services
Positive Influence of Managed Care Plans
Expanded role for nurses
Increased emphasis on health promotion & disease prevention
Negative Influences of Managed Care Plans
Built incentive to limit referrals to specialists
Physicians leaving medicine
Most are for profit organizations
Limited ability to sue managed care organizations
Employment Retirement Income Security Act (ERISA) 1974
Protects employer-sponsored pensions from litigation (HMO’S)
Racketeering Influence and Corrupt Organizations Act
Health Insurance Accountability Act
Ensures can change jobs without losing health insurance coverage
Guarantees coverage for small companies & self-employed individuals
Provides new benefits for self-employed
Consolidated Omnibus Budget Reconciliation Act (COBRA) 1986
Provides insurance when unemployed
Event Beneficiary CoverageTermination or Employee, 18 monthsReduced hrs.Spouse, child
Divorce or Spouse, child36 monthsseparation
Health Care Options
Maintain current Managed Care Plan option
Create National Health Insurance Plan (one-payer system or Universal Health Care)
Managed Competition