USHealthcaresystem美国医疗体制.ppt

USHealthcaresystemUSHealthcaresystem美美国医疗体制国医疗体制LOGOUS Health Care SpendingUS Health Care SLOGOThree Main Parties in Health CarePayer支付方Service Provider服务提供方Patient患者LOGOProvidersvDoctorsDoctorsvHospitalsHospitalsvLaboratoriesLaboratoriesvPharmaciesPharmaciesvPharmaceutical Companies (formularies)Pharmaceutical Companies (formularies)vHome care and other specialty careHome care and other specialty LOGOWhat Do Providers Do? What Do Providers Do? vFamily doctors: one-to-one relationshipvSpecialists: specialty carevHospitals: inpatient and emergency carevDrug stores: drug prescriptionsvPharmaceutical companies: drugs under a “formulary” LOGOPatientvChoose health insurance programs. vPeople over 65 are covered by Medicare. vPeople under a certain poverty line are covered by Medicaid. vEnroll annually (with some exceptions). vStill left 15% of the population “uninsured.”LOGOWhat Do Patients Do?What Do Patients Do?vUninsured: seek emergency care or MedicaidvInsured:§Choose a family doctor §Family doctor becomes the “care manager”§Family doctor must make referral to hospitals §Make co-pay as defined by payers (office visits, generic / brand name drug, out-of-pocket maximums, etc.) LOGOPayersvGovernment: Medicare and state Medicaid programsvHealth insurance programs / HMOvPLOGOWhat Do Payers Do?What Do Payers Do?vPay claims submitted by providers.vEstablish “reasonable and customary” fee schedule.vProvider contracting based on price and quality.vManage care through pre-authorization, referrals, case management, and preventive care. LOGO §People stay healthy§Diseases are diagnosed early §Minimize disease complicationsWhat benefits health insurance LOGOHealth Insurance Companies Keep Provider Health Insurance Companies Keep Provider Costs DownCosts DownvPhysician contractingvHospital contractingvFormularyThis removes all “extra benefits” from providers and allow health insurance companies to, in theory, pass the benefits to consumers.这排除了服务提供方的“额外收益”，而将此利益让渡给医疗保险公司，理论上说，是消费者受益。

LOGO A Private Third Party Payer is the key to keep US Health Care System in Balance LOGOCompetition after PrivatizationCompetition after PrivatizationProviders must compete for Payer business.Payers must compete for Patient business.Each market must have multiple Payers (A, B, and C insurance companies)Each market must have multiple Provider networks.Compete on both price and LOGOMedicare and MedicaidMedicare and MedicaidvFederal Government is by far the largest payer through Medicare and Medicaid.vMedicare is for people 65 years of age and older. vMedicare spending will more than double in the next decade, from $309 billion in 2004 to $792 billion in 2015. vMedicaid spending is expected to increase from $293 billion to $670 billion during the same LOGODifferences between Health Insurance Differences between Health Insurance and National Health Planand National Health Plan•Click to add Text•Click to add Text•Click to add TextHealth insurance companies are private business with P&L responsibilitiesAdverse selectionPre-existing conditionInvestment in health improvementNational Health Plan is an entitlement program not subject to above concerns and should be lower cost to implement. National Health PlanNational Health PlanHealth InsuranceHealth ILOGOWhy Do We Need Health Insurance?Why Do We Need Health Insurance?High cost at High cost at unpredictable unpredictable frequencyfrequency80-20 rule80-20 ruleCurrent money for current needsCurrent money for current LOGOUS Health Care Reform MapCurrent US Status High cost High quality for the rich 15% uninsured National Health CareProponents 赞成方 People Businesses GovernmentObstacles 阻碍方 Current stakeholders who stand to lose LOGOTimeline of Obama CarevPeople under 26 can be covered by parentsvNo pre-existing condition for childrenvLife time / annual limits removedvNo policy cancellation after a person gets ill vHealth plans must offer electronic recordsvNo pre-existing conditions, health status, nor gendervCitizens pay fine for not joining health insurancevEmployers pay fine for not offering health insurance2010 - 20112013 - LOGO结束结束 。