Review of Lecture Four Developing World � BIOE 301 Cardiovascular diseases, 1. Cancer (malignant neoplasms), 2. Unintentional injuries, and 3. HIV/AIDS 4. Lecture Five Developed World � Cardiovascular diseases, 1. Cancer (malignant neoplasms), 2. Unintentional injuries, and 3. Digestive Diseases 4. 1. Heart Disease 2. Cancer � What is one of the most common first � Name three common cancer screening signs that a patient has ischemic heart tests. disease? � Why don’t we screen everyone with these � What are four treatments of ischemic tests? heart disease? � Drug eluting stents have been in the news lately. Why? http://www.npr.org/templates/story/story.php?storyId= 112264556 � Overview of Lecture 5 Unit Two � Eight Americas Every nation, whether it has many � Health Systems healthcare resources or only a few, must � What is a health system? make decisions about how to use those � Goals of a health system resources to best serve its population. � Functions of a health system � Types of health systems � Performance of Health Systems � Examples of health systems � How have health care costs changed over time? � Health Care Reform in the US
What is the difference in life expectancy between the America with the longest life expectancy and the America with the shortest life expectancy?
Summary of County Life Expectancy Patterns How Many $ to Gain a Year of Life? � Male life expectancy rising faster than � Need a way to quantify health benefits female life expectancy � How much bang do you get for your buck? � Best counties have life expectancies � Ratio higher than the country with the highest � Numerator = Cost life expectancy (Japan) � Denominator = Health Benefit � Several examples � Worst counties demonstrate little or no � $$/year of life gained progress in 20 years � $$/quality adjusted year of life gained (QALY) � $$/disability-adjusted year of life (DALY) � Gap between best and worst is widening � Can we use this to make decisions about what we pay for? Dr. Chris Murray, Institute Director, Institute for Health Metrics and Evaluation League Table Table 1.4 Sources of Health Insurance Coverage for the Under 65 Population, 1980-2000 Over the last two decades, private coverage has declined, public coverage has stayed Therapy Cost per QALY about the same, and the uninsured have grown. 90 83% Motorcycle helmets, Seat belts, Immunizations Cost-saving Any Private 80 74% 74% 70 Anti-depressants for people with major depression $1,000 ESI 69% 60 Hypertension treatment in older men and women $1,000-$3,000 50 Pap smear screening every 4 years (vs none) $16,000 40 30 Driver’s side air bag (vs none) $27,000 Uninsured 16% 20 Any Government 15% Chemo in 75 yo women with breast CA (vs none) $58,000 14% 10% 10 9% 8% Medicaid Dialysis in seriously ill patients hospitalized with renal $140,000 0 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 failure (vs none) Notes: ESI - Employer Sponsored Insurance. Any Private includes ESI and individually purchased insurance. Any government includes Screening and treatment for HIV in low risk $1,500,000 Medicare for the disabled population. populations Source: Tabulations of the March Current Population Survey files by Actuarial Research Corporation, incorporating their historical adjustments. Centers for Medicare & Medicaid Services What Happens When You Don’t Table 3.30 Births Financed by Medicaid as a Percent of Total Births Have Health Insurance? by State, 1998 Medicaid pays for about 1 in 3 of the nation’s births. � United States WA NH ME VT MT ND MN � If you meet certain income guidelines, you are OR WI NY MA ID SD MI RI eligible for Medicaid WY CT PA NJ IA NE OH DE NV IN � Texas: TANF (welfare) recipients, SSI recipients IL MD UT WV VA CO DC CA KS MO KY � Eligibility rules and coverage vary by state NC TN OK AR SC NM AZ � State pays a portion of the costs, federal govt. AL GA MS TX LA matches the rest FL AK Less than 28.8% 28.8% to 33.9% 34.0% to 41.3% HI More than 41.3% No data Note: CO, GA 1997 data; KY, NJ, VT 1996 data. Source: Maternal and Child Health (MCH) Update: States Have Expanded Eligibility and Increased Access to Health Care for Pregnant Women and Children, National Governors Association, February, 2001, Table 23, at http://www.nga.org. http://www.coaccess.com/images/mcdCard.gif Centers for Medicare & Medicaid Services
What Happens When Medicaid A Tale of Two Children Doesn’t Cover a Service? � Oregon – August, 1987 � Oregon – July, 1987 � Coby Howard � Oregon state constitution required a balanced � 7 year old boy state budget, surplus returned to taxpayers � Developed leukemia � Required a bone marrow transplant � Voted to end Medicaid coverage of transplants � Was denied coverage � Typically 10 transplants performed per year � Mom appealed to legislature, denied coverage � $100,000-$200,000 per transplant � Mom began media campaign to raise $$ � $1.1 M cost to state (federal govt. pays the rest) � Raised $70k ($30k short of goal) � Coby died in December, 1987 � Voted to fund Medicaid coverage of prenatal � Coby was “forced to spend the last days of his life care acting cute” before the cameras � Would save 25 infants who die from poor prenatal � Ira Zarov, attorney for patient in similar circumstances care A Tale of Two Children Health Systems Face Difficult Choices � Primary goal of a health system: � Oregon, 1987 � Provide and manage resources to improve the health � David Holliday of the population � 2 year old boy � Secondary goal of a health system: � Developed leukemia � Ensure that good health is achieved in a fair manner � Moved to Washington state, lived in car � Protect citizens against unpredictable and high � Washington state financial costs of illness � In many of the world’s poorest countries, people pay � Medicaid covered transplants for care out of their own pockets, often when they � No minimum residency requirement can least afford it � Illness is frequently a cause of poverty � Prepayment, through health insurance, leads to greater fairness Health Systems Types of Health Systems Reflects historical trends in: � � Economic Classification Economic development � � Political Classification: � Political ideology � Entrepreneurial Provide four important functions: � � Strongly influenced by market forces, some government Generate human resources, physical infrastructure & knowledge base to 1. intervention provide health care � Welfare-oriented Provide health care services 2. Primary clinics, hospitals, and tertiary care centers � Government mandates health insurance for all workers, often � Operated by combination of government agencies and private providers through intermediary private insurance agencies � Raise & pool economic resources to pay for healthcare � Comprehensive 3. Sources include: taxes, mandatory social insurance, voluntary private � � Provide complete coverage to 100% of population almost insurance, charity, personal household income and foreign aid completely through tax revenues Provide stewardship for the healthcare system, setting and enforcing 4. � Socialist rules which patients, providers and payers must follow � Health services are operated by the government, and Ultimate responsibility for stewardship lies with the government � theoretically, are free to everyone
Types of Health Systems Entrepreneurial Welfare Comprehensive Socialist Oriented High I ncome United States Canada United Kingdom Soviet Union Developed Germany Spain Japan Greece Australia Middle I ncome Philippines Peru Costa Rica Cuba Developing Thailand Brazil Israel North Korea South Africa Egypt Malaysia Low I ncome Kenya Sri Lanka China Developing Bangladesh Burma Tanzania Vietnam India 100 % of Total Health Expenditures % private 90 % out of pocket 80 70 60 50 40 30 20 10 0 Angola Bangladesh China Sri Lanka India Sout h Africa United Japan Canada Germany Unit ed Stat es Kingdom Developing Countries Developed Countries Entrepreneurial US Health Care System The Nation’s Health Dollar, CY 2000 Medicare, Medicaid, and SCHIP account for one-third of national health spending. � Private Insurance Other Public 1 12% Other Private 2 Medicaid and 6% SCHIP � Conventional 15% � Managed Care: HMOs, PPOs, POS CMS Private Insurance Programs � Government 34% 33% � Medicare Medicare � Medicaid 17% Out-of-pocket 15% � SCHIP Total National Health Spending = $1.3 Trillion 1 Other public includes programs such as workers’ compensation, public health activity, Department of Defense, Department of � Uninsured Veterans Affairs, Indian Health Service, and State and local hospital subsidies and school health. 2 Other private includes industrial in-plant, privately funded construction, and non-patient revenues, including philanthropy. Note: Numbers shown may not sum due to rounding. Source: CMS, Office of the Actuary, National Health Statistics Group. Section I. Page 30 Centers for Medicare & Medicaid Services
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