Understanding Healthcare Economics: Managing Your Career in an Evolving Healthcare System (2nd Edition)

Table of contents

Table of contents :
Cover
Half Title
Title Page
Copyright Page
Dedication
Table of Contents
Foreword
Preface
Acknowledgments
Authors
Introduction
Section I: Pressures for Change
1: Access
Introduction
Sources of Insurance and Characteristics of People Who Are Uninsured
Insurance Sources and Trends
Who Is Uninsured and Why?
Who Is Uninsured?
Why Are Some People Uninsured?
Private Insurance Markets
Insurance Principles: Insurance Is a Mechanism for Managing Risk
How Will the Insurance Company Compute the Premium for a Specific Type of Insurance?
When Will an Individual Decide to Purchase Insurance?
Application of Insurance Principles in Markets for Health Insurance
Health Insurance for Preexisting Conditions: Risk versus Subsidy
Insuring Risk versus Subsidizing an Expenditure
Summary of Explanation of Insurance Premiums and When to Buy Insurance
Why Do Some Employers Offer Health Insurance While Others Do Not?
Employers Don’t Actually Pay for Employer-Sponsored Healthcare
What Forces Shift the Cost of Employer-Sponsored Health Insurance onto Workers?
Basic Economic Tools: Supply and Demand
Basic Economic Tools: At the Equilibrium Wage, Quantity Supplied Is Equal to Quantity Demanded
What Happens When the Actual Wage Is above (or below) the Equilibrium Wage?
Why Is the Equilibrium Concept Useful?
How Does Employer-Sponsored Health Insurance Affect the Equilibrium Wage?
Scenario 1
Scenario 2
Implications of Scenarios 1 and 2
An Inefficient Healthcare System Means Lower Wages for Workers
Healthcare Coverage Mandates Lead to Higher Costs for Health Insurance and Lower Wages for Workers
Why Do Some Individuals Remain Uninsured, Even Though They Are Eligible for Public Insurance or ESI?
Why Do Insurance Companies Utilize Restrictive Practices That Make It Impossible for Some Individuals to Purchase Insurance
Industry Reasons for Using Restrictive Practices
The “Lemons Problem”
Lemons Problem in Health Insurance Markets
Employer-Sponsored Health Insurance Mitigates the Lemons Problem
Solution Strategies
Pre-PPACA Legislation to Restrict the Use of Preexisting Condition Exclusions
Title I of HIPAA: Prohibit Restrictive Practices in the Markets for Small Group and Large Group Health Insurance
State Reforms That Preceded PPACA Reforms
Pre-PPACA Estimates of the Impacts of Alternate Strategies for Increasing Access
Employer Mandate with or without Individual Mandate
Expand Public Programs, Chiefly Medicaid
Tax Credit
ACA Solution Strategy for Increasing the Proportion of Individuals Covered by Health Insurance
ACA Strategy for Increasing Health Insurance Coverage
Mandates That Employers Must Offer Group Insurance, Mandates That Individuals Must Obtain Insurance Coverage, and Ban on Provisions in Health Insurance Policies That Exclude Preexisting Conditions from Coverage
Creation of State-Level Health Insurance Exchanges
Expansion of Medicaid Eligibility for Adults with Incomes up to 100% of the FPL
Impacts
Conclusion
2: Cost
Introduction
Background Information
Definitions: Cost, Price, and Expenditures
Healthcare Expenditures by Type
Sources of Funding for Healthcare Expenditures
Sustainability of the Public Expenditures
Diagnosing the Problem: What Is Fueling the Cost Increases?
Technology Is a Key Driver of Healthcare Expenditure Increases
Value Produced by the New Technologies Compared with the Costs of the Treatments
Do the New Treatments Improve Health?
Are the New Treatments a Good Investment as Measured by Cost per Life Saved (or Cost per Life-Year Saved)?
Solution Options
Option 1: Continue to Spend More on Healthcare Every Year, and Accommodate This by Spending Less on Other Goods
Option 2: Restrain the Quantities of Healthcare Services That Are Utilized Annually in the United States
Ration by Price
Ration by Wait Time
Ration by Setting Priorities
Option 3: Reduce the Rate of Technological Innovation by Reducing the Incentive for Firms to Invest in R&D
Option 4: Reduce the Cost of Delivering Care by Regulating Prices and/or Profits of Healthcare Providers and Pharmaceutical Companies
Regulate Prices and/or Profits of Healthcare Providers and Pharmaceutical Companies
Option 5: Implement Strategies to Make Our Healthcare System More Efficient
Conclusion
3: Quality
Introduction
Background Information: Three Types of Evidence Indicate That Quality Is Not Consistently High
International Comparisons Indicate That Other Countries Are Doing More With Less
What Can We Conclude about This Evidence?
Diagnosing the Root Cause of the Quality Problem
Evidence Documents the Occurrence of Preventable Medical Errors
Evidence Documents Variations in Regional Treatment Patterns
What Is Influencing Physician Decisions?
Does Higher Healthcare Spending Produce Better Outcomes?
Are the Regional Differences Large Enough to Be Important?
Solution Options: How Can We Make Our Healthcare System More Systematic?
Applying Total Quality Management Principals to Healthcare
Brief History
Implement Systematic Protocols: Clinical Pathways and Guidelines
Clinical Pathways
Clinical Guidelines
Conclusion: Some Strategies for Strengthening Quality Are Clear, but the Concept of Healthcare Quality Is Complex and Multidimensional
Conclusion to Section I
Section II: Strategies to Increase Efficiency
Introduction
Do Healthcare Markets Operate Efficiently?
Two Key “Market Failures” in Healthcare
How Should Government Address These Market Failures?
4: Align Incentives via Payment System Design
Introduction
Background: Alternate Hospital Payment Designs
Strategies to Control Cost: Rate Design Replaced Certificate of Need Programs
FFS Payments for Hospital Services and Certificate of Need Programs
Rate Redesign
DRG Payment for Hospital Services
Capitated Payment for Physicians; Accountable Care Organizations for Wider Sets of Providers
Bundled Payment: Eliminate Silos
Selective Contracting
Pay for Performance and Consumer Information to Incentivize Increased Quality
Current Efforts: Value-Based Purchasing for Hospitals
Physician Payment Systems: RBRVS and MACRA
Implications of Public and Private Payment Systems for Hospitals
Conclusions
5: Managed Care Organizations, Accountable Care Organizations, and Patient-Centered Medical Homes
Introduction
Background: Managed Care Organizations
Managed Care: Historical Trends
Managed Care: The Backlash
Current Issues: Lessons Learned
Defining   Consumer Protection  Is Complex
Shifting to Managed Care and/or ACOs Focuses on a Definition of   Quality  that is New for Many Patients
Growth of Managed Care Organizations Raised Two Types of Market Power Issues
Reducing Healthcare Cost by Reducing Provider Reimbursement Sounds Good, if You Are a Consumer, but Providers See a Different Side of the Issue
Providers Responded in Two Ways
Managed Care Organizations Also Raised Questions about Physician Risk Taking and Solvency Regulation
Mental Health Parity Mandate May Constitute a Special Case
Physician Rating Systems Raise Concerns
Do ACOs and PCMHs Deliver on Improving Quality and Coordination of Care at a Reduced Cost?
Conclusion: Experiences with Managed Care Organizations Provide Significant Lessons Learned, as Providers Begin Forming ACOs and PCMHs
6: Wellness, Prevention, and Disease Management
Introduction
Background: PPACA Focuses Increased Attention on Prevention and Wellness
Current Issues
After We Identify Individuals Who Are Most Likely to Benefit from Prevention Programs, Can We Design Programs to Successfully Induce Them to Participate?
Effectiveness of Prevention and Wellness Programs
Conclusions
7: Regulatory Challenges Posed by New Types of Competition in Healthcare
Introduction
Background
Current Issues
New Types of Providers: Retail Clinics, SSHs, Telemedicine, and Integrated Care Providers
Retail Clinics
Single-Specialty Hospitals
Telemedicine
Integrated Care Providers
Conclusion
8: HIT = EMR + HIE
Introduction
Background
If HIT Can Generate Net Benefits, Why Are Federal Subsidies Needed to Boost Adoption?
Expected Benefits versus Costs
Potential Market Failures
Rationale for Investing Taxpayer Dollars in HITECH Subsidies
HIT Adoption Rates Prior to the HITECH Act
Challenges
Impact of the HITECH Act
Impact on HIT Adoption
Impact on Outcomes
Statewide versus Private-Sector HIE
Conclusions
Conclusion to Section II
Conclusion
References
Index