The Structure of Health Insurance

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Del curso dictado por University of Pennsylvania

The Economics of Health Care Delivery

105 calificaciones

University of Pennsylvania

The Economics of Health Care Delivery

105 calificaciones

Curso 2 de 4 en SpecializationThe Business of Health Care

In this course, you’ll learn about the key components of health care, and the economics behind their principles and pricing strategies. Professors Ezekiel Emanuel of Penn Medicine and Guy David of the Wharton School have designed this course to help you understand the complex structure of the health care system and health insurance. Through study and analysis of providers and insurance through an economic lens, you’ll learn how basic economic principles apply to both principles and payment methods. By the end of this course, you’ll be able to identify different types of health care providers and understand the dynamic between the providers and patient so you can employ best practices and maximize profit for your health care organization.

De la lección

Module 1

This module was designed to give you a deeper understanding of the history and structure of the American health care system. You’ll begin by examining the history of health care providers and improvements in health care technology throughout the years. Then you’ll look at the different evolutions of insurance throughout history, the purpose of health insurance, and the inherent issues and solutions within the concept of insurance. You’ll learn key aspects of Medicare, Medicaid, and other government programs that increase access to health care. Then, you’ll evaluate the Iron Triangle of Health Care—quality, cost, and access—and the main areas of focus and tension for health care policy. By the end of this module, you’ll have a richer understanding of the growth of health care providers, insurance, and government programs and their impact on health care access.

History: Providers8:56

History: Health Insurance5:50

History: Government Programs3:31

Introduction to Health Insurance5:57

The Structure of Health Insurance5:45

Medicaid and Other Government Programs4:44

Conoce a los instructores

Ezekiel J. Emanuel, MD, PhD
Diane v.S. Levy and Robert M. Levy University Professor
Department of Medical Ethics and Health Policy
Guy David, PhD
Gilbert and Shelley Harrison Associate Professor of Health Care Management
Department of Health Care Management

Well, with that introduction to health insurance,

here's how it breaks down in the United States.

There's about 310 million people in the country.

About 50 million, a little less than 50 million of them don't have insurance.

And doesn't mean they don't get health care services,

doesn't mean they don't go to the doctor,

or don't need a hospital,

it just means that they don't have health insurance to pay for it.

That leaves about 260 million Americans who have health insurance.

Now, that's broken down into two large groups.

One large group is people who have

private insurance and that is they get insurance through a company,

another is people who get public coverage through the government and government programs.

When we consider the private insurance side,

they are further broken down into two groups.

The first and by far the largest group of

about 150 million Americans gets health insurance through employers.

Either they're the worker or they're the family of a worker.

The benefit of employer sponsored insurance or ESI is that company pulls all the workers.

So in a company have the law of large numbers.

Now that means that large employers have a big advantage because they have more workers,

more predictable health care costs,

more likely to have some sick people and some healthy people.

Small employers are the small group market.

Actually is much more unpredictable.

If you have only nine or 10 employees in a insurance plan,

who knows who's going to get sick?

Who knows when they're going to get sick?

It's much more unpredictable and typically insurance companies build in a risk premium.

They charge more because of that unpredictability.

About 15 or 16 million Americans buy their private insurance themselves.

They actually contract with an insurance company themselves to get health coverage.

They are subject to the law of one number.

There's a small group,

an individual market and they are typically what's called experience rated.

They pay based upon whether they're healthy or sick.

Healthy people pay less,

sick people pay a lot more or don't even get

insurance because they're too high a risk for the insurance company.

This is a very volatile market and it's not easy to get insurance in this market,

and often you don't get very good insurance.

In addition to the private insurance side I

mentioned there's also the public insurance side which we'll talk about next.

On the private insurance side there are

large numbers of both for profit and not for profit insurance companies.

There are the Blue Cross and Blue Shield plans.

Many are state based and they typically are not for profit plans.

And then there are big for profit commercial insurance

which covers the majority of the people in the employer sponsored market.

UnitedHealthcare, WellPoint, Aetna, Cigna, Humana.

These for profit companies take

a premium and have three components of how they spend the money.

The largest component is paying for medical services or medical bills.

There's also a component for the administrative costs,

the paperwork associated with paying the bills.

The pre-authorization to make sure that a person really needs a test

that has been ordered and other elements of administration.

In addition, they have to have a profit at the top.

Even if they are not for profit they have to have a margin to reinvest in the company.

Now, the medical loss ratio or MLR

is the amount that an insurance company pays for medical services.

Why is it called a loss ratio?

Well, that's because it's from the perspective of

the business or the investors in a for profit company.

Every payment of a medical bill is a loss of profit.

Medical loss ratio is typically a higher one,

means that more of the premium goes to medical services,

a lower one means less of the premium goes to medical services and more goes to profit.

It's not clear how much is the right MLR,

but a lot of people think that for big employers an insurance company should pay out

at least 85 cents of every premium dollar for medical services or have an MLR of 85.

And you can see here the various different medical expenses

by the big insurance companies.

Health insurance in the United States is not cheap,

it actually cost a lot of money.

Last year the average premium for a family health insurance plan was $16,000.

And the worker contributed out of pocket an average of

$4,000 for that health insurance plan or about 25 percent,

with 75 percent being contributed through the employer.

That's 75 percent remember contributed by the employer

is not taxed as income or on the payroll for the worker.

And that's one of the advantages when an employer pays the full amount.

You can see that the health insurance system is very complex and very expensive.

Next, we're going to talk about the public health insurance program.

Medicare, Medicaid, and the variety of

other public programs to cover health care costs for different groups in America.

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