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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