U.S. Healthcare System Overview in 90 minutes or less Stakeholders Major challenges.
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Transcript of U.S. Healthcare System Overview in 90 minutes or less Stakeholders Major challenges.
U.S. Healthcare System
• Overview in 90 minutes or less
• Stakeholders
• Major challenges
STAKEHOLDERS
• Patients/clients/customers
• General Public
• Employers
• Governments
• Insurance Plans
• Providers
CHANNEL OF DISTRIBUTIONINPATIENT SURGERY
CONSUMER
INSURER
PCP
SURGEON
HOSPITAL
EMPLOYER
PER CAPITA HEALTH EXPENDITURES
0
500
1000
1500
2000
2500
3000
3500
4000
4500
U.S. Norway Austria U.K. Poland
1999
HEALTH CARE TRIANGLE
COST
QUALITY ACCESS
Total U.S. Health Expenditures
0
200
400
600
800
1000
1200
1400
1600
1800
1965 1970 1980 1990 2000 2005
$ Billions
STAKEHOLDERS: THE PUBLIC
• Potential patients
• Taxpayers
• Purchasers of other goods and services
• Expectations?– Is health care a right like public education or
police protection?
• When do they show interest?
Projected Growth in U.S.Population Age 65 and Older
0
10
20
30
40
50
60
70
1980 1990 2000 2010 2020 2030
Millions
STAKEHOLDERS:EMPLOYERS
• Pay most of the private insurance premiums
• Taxpayers
• Competing for workers
• Competing globally for markets
• >10% premium increases
• How are they coping?
STAKEHOLDERS:GOVERNMENTS
• DOMINANT PAYER (ABOUT 50%)– Medicare, Medicaid, VA
• HUGE REGULATOR– Federal, State, Local
• DIRECT PROVIDER– VA– State hospitals, clinics, health departments– County/City hospitals, clinics, health departments
• POLITICS
STAKEHOLDERS:INSURANCE PLANS
EVOLUTION• 1930’s—Blue Cross• POST WW2—Rapid growth of employer based
plans• 1980’s—Managed Care• Integrated networks
STAKEHOLDERS:INSURANCE PLANS
FUNCTIONS
• Develop coverage plans
• Contract with providers
• Market the plans
• Underwrite
• Manage utilization, quality, cost
• Administer claims
STAKEHOLDERS:INSURANCE PLANS
STATUS• Cyclical profit and loss • Return to rapid premium increases• Consolidation• Backlash against controls
– Consumers
– Politicians
– Courts
STAKEHOLDERS:INSURANCE PLANS
KEY ISSUES• Control total cost
– Number of services used
– Cost per unit of service
• Manage (shift) the risk• Satisfy consumers, regulators, courts
STAKEHOLDERS:PROVIDERS
• HOSPITALS• OUTPATIENT CENTERS• PHYSICIANS• OTHER CLINICIANS• LONG-TERM CARE• MENTAL HEALTH• PUBLIC HEALTH
HOSPITALS
HISTORY
1873 178
1909 4,300
1946 6,000
1970’S 7,200
2000’S <4,000
HOSPITALS
STATUS• Losing money• Upward pressure on costs
– Critical staff shortages– Legislative/judicial mandates– Insurance premiums
• Increasing inpatient volume• Competition for outpatients
Inpatient Admissionsin Community Hospitals
28
29
30
31
32
33
34
35
36
37
1980 1985 1990 1995 2000 2003
Millions
HOSPITALS
CHALLENGES• Reposition philosophy, organization, facilities
– Emergency, Critical Care, outpatient services
• Re-establish partnerships with physicians• Continue to invest in technology• Employer of choice, again• Public accountability and confidence• Advocate national health policy: fix payment syst.
OUTPATIENT CENTERS
• START WITH: GP’s office, Hospital indigent clinics, Hospital ER’s, public health clinics
• ADD: Group practices, Hospital outpatient departments, specialty clinics
• NOW: Freestanding centers– Primary care, urgent care, surgery, imaging, eye
treatment, gastro-intestinal, and on and on
OUTPATIENT CENTERS
STATUS
• Burgeoning volume (Why?)
• Diverse ownership
• Increasing regulatory and insurance plan scrutiny
OUTPATIENT CENTERS
CHALLENGES
• Anticipate technology changes
• Maintain quality and public confidence
• Maintain profitability with lower payments
• Increasing competition
PHYSICIANS
EVOLUTION:
Doc-in-a-buggy to Doc-in-a-box
• Solo practice
• Group
• Multi-specialty group
• Employee
PHYSICIANS
STATUS• 60 to 70% Specialists, most clustered around
Academic Medical Centers• Not enough Primary Care in many places• Dramatic decline in payments• Baby boomers retiring: shortages ahead?• Lost power to insurance plans• Cost pressure: labor, insurance premiums, regs
PHYSICIANS
CHALLENGES
• Re-establish control of patient care
• Negotiate better payments/contracts
• Reform malpractice liability system
• Anticipate changes in technology and competition; establish long-term position
• Replace retiring colleagues
LONG-TERM CARE
EVOLUTION
• Mom and Pop rest homes
• Neglect and abuse scandals: regulation
• Corporate owned skilled nursing facilities
• Diversity in settings and types of patients
LONG-TERM CARE
STATUS• SNF’s
– Declining occupancy last 15 years• Older adults healthier• Vast increase in options• Federal prospective payment
– Will reverse with dramatic increase in numbers of “super-elderly” over next 25 years
– Medicaid is largest payer
LONG-TERM CARE
• Assisted living– Rapid growth: expect to double by 2025– Often part of retirement community– Private pay
• Adult Day Care– Another option; small but growing– Private pay
LONG-TERM CARE
• Home care– Fastest growing segment of U.S. health – Mix of long and short-term– Medicare is largest payer, cutting payments
• Hospice– Offered in many settings– Growing recognition of value – Medicare pays
LONG-TERM CARE
CHALLENGES• Demographics: over 65 will double from year
2000 to 2030; over 85 will increase more rapidly• Family changes: career women, or 70 year old
“child” unable to care for 90 year old parent• Technology: extends life, diversifies care options
LONG-TERM CARE
CHALLENGES (continued)• More sophisticated consumers: aware of
options• Government scrutiny: pressure for high
quality; budget crunches• Labor shortages: traditionally lower pay and
benefits than hospitals and outpatient centers
MENTAL HEALTH
HISTORY: Grim and grimmer• Locked in asylums (or worse)• 1930’s to early 60’s: development of shock
therapies and first effective drugs increased ability to manage inpatients
• 60’s to 80’s: Community mental health centers; reduced funding for inpatients; marketing competition for private dollars
MENTAL HEALTH
STATUS
• Tremendous capabilities to specifically diagnose and effectively treat most forms of severe mental illness
• Only half of severe and persistent mentally ill receive treatment
• Insurance coverage significantly limited
MENTAL HEALTH
CHALLENGES
• Stigma, misperceptions
• Unresolved public policy debate: maintaining mental health VS. treating severe and persistent illness
• Insurance limitations resulting from above
• Patient compliance with treatment
PUBLIC HEALTH
EVOLUTION
• Sanitary reform
• Epidemic control
• Prevention, education, immunization
• Unable to compete with M & M for funds
• Renewed interest because of terrorism, new viruses
PUBLIC HEALTH
STATUS
• Less than 1% of U.S. health dollars are spent for public health
• Greatly increasing public demand for management of new diseases, water supply, food supply, and more
PUBLIC HEALTH
CHALLENGES
• Strong cultural bias favoring cure of the individual over promotion of the general health of the population
• Convert current public concerns into political clout for increased funding