8.

19 INTRO AND COURSE OVERVIEW

Roemer model of health system

o management,
o the production of resources that support the system
o organization
o the sources of economic support
o How services are delivered

8.21 INTRO TO TEAM PROJECT

8.26 POPULATION HEALTH & DETERMINANTS OF HEALTH
Learning objectives:
Understand the determinants of health
1.
2.
3.
4.
5.
Describe key measures of population health status
1.
2.
3.
4.

Describe the health status of the U.S. population

1. Two top killers: __________ & ____________
2. Area of great improvement:
3. Area of great increase (sadly):
Define health:
Americans spend $______ per person on health every year

Notes

THE MOST IMPT DETERMINANT OF HEALTH IS NOT MEDICAL CARE

How healthy are we?

What does it mean to be healthy?

How do we assess the health of populations?

Data

Diff in pop health status

What explains the diff in indiv and pop health? What are the determinants of
health?
Definition: Health is a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity.
Trends in the Health in the United States, 2013 CDC Report:
What is the top contributors to the mortality rate? Cancer and heart
disease
Areas of great improvement: cholesterol
Increase in childhood obesity
Common measures used to asses and compare the health status of populations:
Life expectancy
Mortality (incidence of deaths in population)
Morbidity (incidence of disease in population)
IMR and birth weight
We spend $7326 per person on health care every year
It might be that we just spend a lot more per service
We also order a lot more stuff for the exact same thing
WHY ARE THERE SUCH GREAT DIFFERENCES IN HEALTH CARE IN
AMERICA? Why do we spend so much money on health care yet our life
expectancy isnt great, our care isnt the best, etc?
Health is influenced by factors in five domains:
Genetics
Social circumstances, e.g. education, income
Environmental exposures, e.g. housing, water, food
Behavioral patterns, e.g. physical activity, tobacco use
Health care

8.28 DETERMINANTS OF HEALTH (CONT.) AND HEALTH DISPARITIES

Understand the determinants of health
Describe health disparities

Understand the reasons for health disparities

Notes:

The US is 30th in life expectancy; the worst of the developed nations

Social class is the most important determinant of life expectancy
When youre stressed, your body releases the stress hormone, cortisol
o
This causes/is correlated with accelerated aging, diabetes, shrunken
neuro pathways, heart damage, etc. basically, more stress = poor health

9.2 library day

9.4 business writing
9.11 INTRODUCTION TO THE U.S. HEALTH SYSTEM

Learning Objectives:
Understand how to evaluate the performance of a health system
Describe the current performance of the U.S. health system, including strengths and
opportunities for improvement

Class Notes
How do we measure the performance of a health system?
1. Healthy Lives
2. Quality
3. Access
4. Efficiency
5. Equity
6. Public views/satisfaction with the system
Institute of Medicines six elements of quality care
1. Effective
2. Safe
3. Patient centered
4. Timely
5. Equitable
6. Efficient

America is the epitome of a country of haves and have-nots

o The more money you have, the better care you receive, more often
screened, less surgery complications, access to a PCP, etc
o As of 2010, 44% (81 million) of adults uninsured or underinsured
o Lots of waste and inefficiency: repeated tests, paperwork issues, admin
stuff, etc.
Equality vs. equity
Most Americans say we need a complete overhaul of Health Care

9.16 INTRODUCTION TO THE AFFORDABLE CARE ACT

Not in this class:
A
A
A
Q
available, accessible, acceptable, quality
Review of key provisions intended to improve health system performance
Access to care
Quality of care
Population health
Efficiency
Equity

Class Notes:

Performance of the US Health System

o
When creating policy, it must be politically feasible
o
Build on current system
o
Ensure people who are currently happy with the system remain happy
o
Compromise with key stakeholders
THE ACA:

Expand Medicaid in 2012 controversial. NC didnt accept it.

o
To individuals w incomes up to 133% of PVL.
o
2014 PVL is $11,670
Establish Health Insurance Exchanges

o Establish exchanges (aka marketplaces) where individuals and small

employers can purchase insurance coverage
o Provide subsidies to help individuals with incomes from 133% to 400%
FPL pay for coverage
o If state doesn't do the subsidies, the federal government will provide the
subsidies. But those that fall under the 133% don't get anything if state did
not expand Medicaid
Employer Mandate
o Employers with 50+ full-time employees required to offer insurance or pay
penalty
Individual Mandate
o Citizens and legal immigrants required to pay penalty if they do not have
qualified health insurance, unless exempt
Insurance Reforms
o Insurers cannot deny, rescind or limit coverage or charge more for
coverage due to health conditions
o Need the indiv mandate for this because those that are most likely to get
insurance are those who are already sick. Then insurance costs will go up.
And healthy people will drop out of insurance
Coverage for Young Adults
o Young adults may remain on their parents health insurance until age 26
Essential Benefits Package
o All qualified health benefit plans (except grandfathered plans) must offer at
least the essential health benefits package (comprehensive set of
services, covers at least 60% of the actuarial value of the covered
benefits)
o Controversy: Obama had said that if you liked your plan, you could keep it.
Then a lot of them didn't meet the requirements (only covered catastrophic
stuff. Not day-to-day, but they only wanted and could afford those plans),
and people had to change
Additional Provisions
o Funding for community health centers and school based health centers;
loan forgiveness for health professionals willing to work in underserved
areas; additional provisions related to strengthening the health workforce
Quality of Care
National Strategy improvement strategy (coordinate federal activities)
Value-Based Purchasing- establish programs based on performance
Public Reporting of Quality Data reporting initiative
Comparative Effectiveness Research

Innovation Center- test and evaluate new models of delivering and paying for
care

Improving Population Health

Prevention & Public Health Trust Fundi
Primary Care & Prevention
o Recommend that clinical preventative care is covered 100% and
incentives to practice, inclu inc payments for PCPs
Community Needs Assessments by non-profits every 3 years
Improving Efficiency

Greater Oversight of Health Insurance Premiums

o 85% of premiums (large group market) and 80% of premiums (small group
market) must be spent clinical services
Reducing Fraud & Abuse and oversight
Administrative Simplification- adopt standards
Increased Competition & Price Transparency (Health Insurance Exchanges)
Testing New Models
Improving Equity
Many of the provision already mentioned have the potential to improve equity

Diverse workforce, more data on disparities, cultural competence training

cultural competence training of health care professionals

9.18 ORGANIZATION OF THE U.S. HEALTH SYSTEM

Learning Objectives:

Describe the key players in the U.S. health system

Describe the complex and chaotic organization of the U.S. health system
Distinguish between public health and health care services
Key Players:
1. patients
2. providers
3. Regulators?
4. Suppliers?
5. Policy-makers?

9.23 THE ROLE OF GOVERNMENT IN HEALTH CARE

Learning Objectives:

Understand the role of government in health care

Identify the major agencies within the Department of Health and Human Services
and their responsibilities

Identify some of the other agencies within the federal government that are directly or
indirectly involved with the health of Americans

Class Notes:

The U.S. Department of Health and Human Services (HHS) is the principal
federal agency in health-related matters
Key roles:

Policy-maker and regulator

Health care provider

Payer

Support research

Support training of health care providers

Public health

Human services
Budget: $1.01 trillion
Agencies that make up HHS:
Food and Drug Administration (FDA)
Primary regulatory agency
Regulation of product ingredients, packaging, labels, marketing
Food, drugs, and stuff that fits in neither
DA regulates eggs, USDA regulates egg products
National Institutes of Health (NIH)
Primary biomedical research organization
Basic Science (what causes disease)
Clinical Science (how can we turn that knowledge into a clinical
application)
Translational Science (how can we put these applications into
practice)
Indian Health Services (IHS)
Centers for Disease Control and Prevention (CDC)
Main public health agency

Monitors and prevents disease outbreaks

Implements disease prevention strategies
Maintains national health statistics
Keeps the strategic national stockpile
Substance Abuse and Mental Health Services Administration (SAMHSA)
Health Resources and Services Administration (HRSA)
Primary focus healthcare workforce and access
Key programs:
Health Centers
Ryan White program

Ryan White program

o
Funding for low-income citizens with HIV/AIDS

Before ACA, there was pre-existing conditions

Care is expensive

Treatment Is prevention; it's communicable

Workforce initiatives
Agency for Healthcare Research and Quality (AHRQ)
Centers for Medicare & Medicaid Services (CMS)
Administration for Children and Families (ACF)
TANF, Head Start, Refugee Resettlement
Administration for Community Living (ACL)
Disability and again policy
To make things even more complicated, responsibility for health is shared by
many U.S. government departments and agencies:
Department of Defense: medical care for active service members
Veterans Administration: medical care for former service members
Department of Homeland Security: disaster response and recovery;
programs to address safety threats
Department of Education: safe and drug free schools
Environmental Protection Agency: clean air and water
Department of Labor: worker safety
Department of Housing and Urban Development: healthy homes;
controlling lead hazards
Department of Agriculture (USDA): nutrition policy and promotion; food
safety
Social Security Administration: disability benefits

9.25 MANAGEMENT OF THE U.S. HEALTH SYSTEM

Learning Objectives:
Identify and describe key examples of U.S. health services legislation

Describe how regulation influences the operation of the U.S. health system

What is the role of gov in the US health system?

Policy-maker and regulator
Health care provider
Payer
Support research
Support training of health care providers
Public health
"Get government out of my health care"
What does that mean?

They're so involved in everything already

What we don't want is the government deciding WHAT care we
receive. We don't really care otherwise...we don't want big brother
You technically can't use comparative use studies to inform policy,
esp in cancer. In UK if there's a drug thats 50k and only extends life a week,
they just say that we can't pay for it. If that happened here.well it wouldn't
What is management?
M&E
Decision-making
Planning

There's not that much system level planning nationally

Administration

Most admin occurs locally and within organizations

Legislation
Can come from all levels
Some important U.S. health services legislation:

1946 Hill-Burton Act

Realized we didn't have the capacity for anything real.

Had A LOT of funding for building hospitals

1965 Titles XVIII (Medicare) and XIX (Medicaid) of Social

Security Act

1973 HMO Act-health maintenance organization act

Diff way to manage expenditures; had great success

on West Cost and wanted to pay for people in a social experiment

Unlike traditional indemnity insurance, an HMO

covers care rendered by those doctors and other professionals who

have agreed by contract to treat patients in accordance with the

HMO's guidelines and restrictions in exchange for a steady stream of
customers. HMOs cover emergency care regardless of the health
care provider's contracted status.

1986 EMTALA

ER cannot deny you service based on if/how you pay

1997 Title XXI (SCHIP) of Social Security Act

Raised low-income level for kids so that more are

under Medicaid

2003 Medicare Rx Improvement and Modernization Act

Medicare now includes prescription drugs

"doughnut hole"-- covered below $XX, then from there

until $YY you have to cover it all. But over $YY, they'll pay again

2010 Affordable Care Act

Regulation
There's a lot of regulation. Especially in becoming a doctor or
bringing a prescription to market

i.e. According to the Tufts Center for the Study of Drug

Development at Tufts University, it takes an average of 15 years for an
experimental drug to go from lab to patient.

i.e path to becoming a physician or bringing a drug to market

Developed and enforced at all levels-federal, state, and local

Also regulated by private orgs

Pros and Cons of Regulations
If there are no regulations, how do we behave and what guides us?