1.2.6 PAYERS for Healthcare Delivery

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Del curso dictado por University of Minnesota

Healthcare Delivery Providers

124 calificaciones

University of Minnesota

Healthcare Delivery Providers

124 calificaciones

Curso 2 de 5 en SpecializationHealthcare Marketplace

Welcome to the exciting world of Healthcare Delivery Providers! This second course in the Healthcare Marketplace Specialization will help you understand the various providers of healthcare across the U.S. delivery continuum. We will explore the unique value proposition of the various providers- from hospitals and clinics to physicians to community based providers. We will dissect this important value chain using various lenses such as- site of care delivery, people who provide the care and payers who pay for care. You will also learn about the challenges facing these providers and the innovations they are creating in order to help transform this important industry. I will use readings such as a case study and videos to make this learning more experiential for you, so that you can see and feel the world of healthcare delivery. I will also explain the various acronyms and specialized terms used in healthcare, so that you become more proficient and familiar with the language. Given the fact that Healthcare is one of the largest industries in the U.S. and growing at an rapid pace, it is critical that current and future leaders understand the internal and external drivers that are shaping this industry. Current and future leaders will need to constantly innovate in order to sustain this industry into the future- by creating value for the end customer and the entire population, as well as increasing engagement of the humans who work within this industry. Get ready to take a deep dive into the complex ocean that is U.S. healthcare delivery- and make sure your oxygen tank is securely fastened!

De la lección

INTRODUCTION TO U.S. HEALTHCARE DELIVERY

Welcome to the world of healthcare delivery providers! In this first module, I will introduce important concepts in this field including how value in healthcare is measured, what some key influencers of healthcare are and how the healthcare delivery system will be examined in this course. We will use various lenses such as: site of care delivery, payment models, payers and humans that work in the delivery system to dissect this value chain. I will also discuss emerging paradigms like the Triple and Quadruple Aims and Accountable Care, which are rapidly spreading across the US healthcare industry.

1.2.1 Overview of the Lenses12:21

1.2.2 SITES of Healthcare Delivery9:12

1.2.3 Moving Boxes7:53

1.2.4 PEOPLE in Healthcare Delivery7:39

1.2.5 PAYMENT for Healthcare Delivery12:10

1.2.6 PAYERS for Healthcare Delivery8:22

Conoce a los instructores

Dr. Rahul Koranne
Faculty
Carlson School of Management, Department of Finance

This is the healthcare delivery providers part of the healthcare

marketplace specialization.

This is module 1.2.6 Payers for Healthcare delivery.

Learning outcomes for this lecture are to understand who pays for

healthcare delivery in the US and

then understand the concept of insurance payment versus a customer or

a patient paying out of pocket for the health care expense.

Private Health Insurance, PHI, Medicare Advantage plans, or MA.

So in our last lecture we looked at how the payment for

some of the healthcare providers is calculated.

And in this lecture we will look at who pays for the healthcare provider.

So a lot of the times it's private health insurers.

So these are insurance companies that are private.

Or sometimes it's the governmental programs.

For example, social welfare programs that we have in the US.

So let's look at those.

This is a chart taken from MedPAC that we have talked about before.

Which looks at the types of purchasers or

insurance companies that pay for healthcare in the US.

So private health insurance companies 34%,

Medicare 22% Medicaid, 17%.

And some of the other payers that make up

the total 2.5 trillion in 2013.

Let's begin with Medicare.

This is the largest governmental payer.

It is a national social insurance program that was introduced in 1966.

It covers and pays for medical expenses for

individuals 65 years and older who have worked and

paid into this pot of money that is used to pay out these expenses.

Also, it covers some other individuals, for example,

younger patients with disabilities or some other very complicated conditions.

For example, end stage renal disease, which is a type of kidney failure

that typically needs dialysis or kidney transplant.

The next biggest governmental program is Medicaid.

This is a social insurance program jointly funded by the Federal government and

the State government, and it is run and managed by each of the 50 states.

This particular program is geared towards individuals and

families who have low income and very limited resources.

So these are the types of individuals, and some of them have disabilities and

other needs, but these are the types of individuals and

families that benefit from this particular social program.

One of the largest payers of

healthcare expenditures in the US are private health insurance companies.

So these are companies that pay for

medical expenses in the form of healthcare insurance.

These can be purchased by either individuals in the market or as

is emerging in the last couple of years, over health insurance exchange, or HIE.

Or these can be purchased in groups of individuals.

For example employees through the employer.

So mostly there are purchased through the employer of groups of

individuals that is their employees.

Now, some of the newer emerging models in private health insurance that you've heard

about in the previous course are high deductible plans, where the deductibles

are higher, and so, the premiums might be lower and these will only pay for

catastrophic illnesses and not for the routine medical expenses.

So that's a tradeoff that individuals and families have to make.

Another new emerging idea is the tax

preferenced health spending accounts or HSAs where individuals and

families can put away some money that is tax preferenced, and

then use it for paying off medical expenses.

So sometimes these are used in combination.

And so again, the direction that a lot of these various models are going

is to start shifting some of the cost and hence some of the accountability

of the health care expenditure directly to the individual and their families.

Let's do a short quiz.

Let's look at some more data from MetPak as we've discussed.

This particular chart looks at Medicare spending in 2013, and

I want you to notice how Medicare versus

Medicaid versus other insurers differ in the various categories of providers.

So for the hospital the other is the highest amount.

Medicare and Medicaid are lower.

For physicians, again, the other insurances,

pay much more than Medicare and Medicaid.

However, for nursing home, you will notice that Medicare and

Medicaid are getting much higher, but still a chunk is paid by other insurance,

for example long term care insurance that some individuals buy.

Home health care is really dominated by the governmental payers of Medicare and

Medicaid, and so on and so forth.

This particular chart, also from MedPAC, shows that the spending by the government

in the form of Medicare is concentrated in certain services.

And is slowly shifting as the health care delivery system changes.

So managed care is increasing, again.

Medicare also partners with private insurance companies through

Medicare Advantage plans, and uses these private insurance plans to do

case management and also administer some of the medicare dollars,

the inpatient hospital has significantly gone down and

we saw that in the previous lectures as well.

The physician fee schedule has also changed slightly and

as you can see, the total spent from 2006 to 2013 has

significantly increased to $574 billion with a b.

Particular chart also from MedPac shows a very important point in payers and

payment in that there's a very small percentage of beneficiaries or

individuals here for Medicare, it's 1%,

that are driving 15% of the program spending and

the next 4% is driving 24% of the program spending.

So, between these 5% of individuals, the spending is almost close to 40%.

So the very highly complicated individuals are obviously the very costly ones,

and they drive the entire national expenditure.

In summary, the governmental payers of Medicare and Medicaid and the private

health insurance companies pay for most of the healthcare delivery expenses.

Some emerging models like the high deductible insurance plans and

other programs are shifting the cost and

the accountability to the consumers, the individuals and the families.

And that is directly impacting the behavior of the individuals,

the families but also on the mega health care delivery system,

as we shall see in the upcoming lectures.

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