AAA_PH 150D Midterm Review Sheet Fall 2014

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PH 150D, UC Berkeley

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PH 150D Midterm ReviewOctober 16, 2014This 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 Key readings that we expect you to be able to recall and cite: Orszag and Ellis 2007 Cutler et al 2006 Commonwealth Policy Brief 2009 Pauly and Pagan 2007 Gusamno et al 2002 Aragon 2001 Gawande 2009 Schroeder 2007 Mechanic and Tanner 2007 Health Leaders Survey 2014 American Hospital Association 2011Outline: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) Concepts:1. Introduction (8/23)2. Health Care in the US (8/30, Orszag, Cutler)a. Culture/Values/Institutions that underpin our health care systemi. Market Justice vs. Social Justice & Implicationsii. Why market failure is common health care marketsb. Cost of Carei. Trends in spending/costs1. Impacts on public and private payers2. Main drivers of health care spendingii. 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 paymentsb. Payment Systemsi. Capitationii. 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 plansii. Experience ratingd. Employer-Based Insurancei. 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 ite. Managed Carei. HMO ii. Preferred provider organizations (PPOs) f. Utilization Controls: Ways care is managedi. Gatekeepersii. Networks of Contract Physiciansiii. Utilization Reviewiv. Physician Practice Profilesv. Financial incentives g. Medical Loss Ratio4. Health Coverage: Individual Market (9/9, Commonwealth Policy Brief)a. Definitions of Insurancei. Random hazardii. Risk pooling iii. Moral hazardiv. Adverse selectionb. 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 stooli. Guaranteed Issueii. Mandateiii. Assistance (information and subsidies)5. Health Coverage: Public Programs - Medicare (9/11, Barr, Chapters 6)a. Medicarei. Different components (Parts A, B, C & D) and who and what they coverii. How financed (who pays)iii. Payment systems1. 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 hole6. Health Coverage: Public Programs - Medicaid (9/16, Barr, Chapters 7)a. Medicaidi. Who and what is coveredii. Who is responsible for managementiii. 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. SCHIPi. Who is covered? ii. Relationship with Medicaid7. The Uninsured (9/18, Barr Chapter 11; Pauly-Pagan; Gusmano et al)a. Uninsuredi. 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 Stakeholdersi. Providers: Physicians, Nurses, Other Practitioners1. Scope of practice ii. Purchasers (e.g., health plan)iii. Manufacturers (e.g., pharmaceutical industry)iv. Patients/Consumersv. Businessesvi. Governmentsvii. Other (e.g., nonprofits, foundations)9. Health Advocacy and the Legislative Process (9/25, Aragon)a. Advocacy types/strategiesi. Legislative, administrative, media, policy research, community-organizing10. Quality of Care (9/30, Gawande)a. What is quality of careb. Evidence-based medicinec. Relationship between quality and spendingi. Regional variation in spending11. 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 Flaggs slides as a guide.)a. What is health?i. Public health vs. health careb. Proportional contribution to premature deathi. Medical care (10%), social circumstances, lifestyle/behavior, genetic predisposition, environmental factorsc. Social determinants of healthd. Health disparitiese. Equity vs. equality1