aaa_ph 150d midterm review sheet fall 2014
DESCRIPTION
PH 150D, UC BerkeleyTRANSCRIPT
PH 150D Midterm ReviewOctober 16, 2014
This review sheet covers themes and concepts from the readings and lecture for which you should know the definition and significance for U.S. health policy
Outline:1. Introduction (8/28)2. Health Care in the US (9/2, Barr, Chapters 2 & 3; Orszag; Cutler)3. Health Coverage: Employer Based Insurance (9/4, Barr, Chapters 5 & 8)4. Health Coverage: Individual Market (9/9, Commonwealth Policy Brief)5. Health Coverage: Public Programs - Medicare (9/11, Barr, Chapter 6)6. Health Coverage: Public Programs – Medicaid (9/16, Barr, Chapters 7)7. The Uninsured (9/18, Barr Chapter 11; Pauly-Pagan; Gusmano et al)8. Stakeholders (9/23, Barr, Chapter 4, link)9. Health Advocacy and the Legislative Process (9/25, Aragon)10. Quality of Care (9/30, Gawande)11. Putting the “H” in HPM (10/2, Schroeder; Mechanic and Tanner)
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Key readings that we expect you to be able to recall and cite:o Orszag and Ellis 2007o Cutler et al 2006 o Commonwealth Policy Brief 2009 o Pauly and Pagan 2007o Gusamno et al 2002o Aragon 2001o Gawande 2009o Schroeder 2007o Mechanic and Tanner 2007o Health Leaders Survey 2014o American Hospital Association 2011
Concepts:
1. Introduction (8/23)
2. Health Care in the US (8/30, Orszag, Cutler)a. Culture/Values/Institutions that underpin our health care system
i. Market Justice vs. Social Justice & Implicationsii. Why market failure is common health care markets
b. Cost of Carei. Trends in spending/costs
1. Impacts on public and private payers2. Main drivers of health care spending
ii. Relationship between spending, health outcomes, and quality of care1. Value for medical spending?
3. Health Coverage: Employer Based Insurance (9/4, Barr, Chapters 5 & 8; Blumenthal)
a. Basic definitionsi. Premium
ii. Deductibleiii. Co-paymentsiv. Co-insurancev. Out-of-pocket payments
b. Payment Systemsi. Capitation
ii. Fee for service (FFS)
KEY: Know how different payment systems shift financial risk; change provider/facility incentives, and influence the quality of care.
c. History of Insurance in the USi. Indemnity plans
ii. Experience ratingd. Employer-Based Insurance
i. “Accident” of History: Employer-Based Coverage ii. Health Care as a Fringe benefit
iii. Employee Cost-Sharing (see part 3a above)iv. Gaps: why a person might not be able to get it
e. Managed Carei. HMO
ii. Preferred provider organizations (PPOs) f. Utilization Controls: Ways care is “managed”
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i. Gatekeepersii. Networks of Contract Physicians
iii. Utilization Reviewiv. Physician Practice Profilesv. Financial incentives
g. Medical Loss Ratio
4. Health Coverage: Individual Market (9/9, Commonwealth Policy Brief)a. Definitions of Insurance
i. Random hazardii. Risk pooling
iii. Moral hazardiv. Adverse selection
b. Individual Marketi. How it differs from Employer-Based Coverage (also known as Group
Market) 1. Underwriting: Community vs. Individual Rating2. “Cherry picking” (avoid adverse selection)3. Different incentives for individuals and insurers4. Paradox: Why some might not be able to get individual market
insurancec. Three-legged stool
i. Guaranteed Issueii. Mandate
iii. Assistance (information and subsidies)
5. Health Coverage: Public Programs - Medicare (9/11, Barr, Chapters 6)a. Medicare
i. Different components (Parts A, B, C & D) and who and what they cover
ii. How financed (who pays)iii. Payment systems
1. Diagnosis-related group (DRG) or prospective payment systemiv. Gaps: why a person might not be able to get it. Things not covered.v. Current Issues in Medicare:
1. Long-term viabilityvi. Part D: Doughnut hole
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6. Health Coverage: Public Programs - Medicaid (9/16, Barr, Chapters 7)a. Medicaid
i. Who and what is coveredii. Who is responsible for management
iii. How is it financed: FMAP, FPLiv. Gaps: why a person might not be able to get it. Things not coveredv. Variation of Medicaid programs across states
1. Mandatory and optional benefits2. Different decisions on who and what to cover, who delivers
services, and reimbursement ratesb. SCHIP
i. Who is covered? ii. Relationship with Medicaid
7. The Uninsured (9/18, Barr Chapter 11; Pauly-Pagan; Gusmano et al)a. Uninsured
i. Limitations of Employer-Based Insurance, Individual (self-purchased) Insurance, and Public Insurance (Medicaid, Medicare)
ii. Who are the uninsured?iii. Cost of uninsurediv. Who pays for their care?
1. Cost shiftingv. Impact on health care quality & cost
1. Spillovers (financial and nonfinancial) b. Who are the “safety net” providers for the uninsured?
8. Stakeholders (9/23, Barr, Chapter 4)a. Healthcare Stakeholders
i. Providers: Physicians, Nurses, Other Practitioners1. Scope of practice
ii. Purchasers (e.g., health plan)iii. Manufacturers (e.g., pharmaceutical industry)iv. Patients/Consumersv. Businesses
vi. Governmentsvii. Other (e.g., nonprofits, foundations)
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9. Health Advocacy and the Legislative Process (9/25, Aragon)a. Advocacy types/strategies
i. Legislative, administrative, media, policy research, community-organizing
10. Quality of Care (9/30, Gawande)a. What is quality of careb. Evidence-based medicinec. Relationship between quality and spending
i. Regional variation in spending
11. Putting the “H” in HPM (10/2, Schroeder; Mechanic and Tanner) (NOTE: This will be different, because this was done as a guest lecture in the fall, but Professor Flagg is lecturing on this in the summer, so use Professor Flagg’s slides as a guide.)
a. What is “health”?i. Public health vs. health care
b. Proportional contribution to premature deathi. Medical care (10%), social circumstances, lifestyle/behavior, genetic
predisposition, environmental factorsc. Social determinants of healthd. Health disparitiese. Equity vs. equality
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