USHealthcaresystem美国医疗体制.ppt

1、US Health Care System,US Health Care Spending,Three Main Parties in Health Care,Payer 支付方,Service Provider 服务提供方,Patient 患者,Providers,Doctors Hospitals Laboratories Pharmacies Pharmaceutical Companies (formularies) Home care and other specialty care,What Do Providers Do?,Family doctors: one-to-one r

2、elationship Specialists: specialty care Hospitals: inpatient and emergency care Drug stores: drug prescriptions Pharmaceutical companies: drugs under a “formulary” arrangement,Patient,Choose health insurance programs. People over 65 are covered by Medicare. People under a certain poverty line are co

3、vered by Medicaid. Enroll annually (with some exceptions). Still left 15% of the population “uninsured.”,What Do Patients Do?,Uninsured: seek emergency care or Medicaid Insured: Choose a family doctor Family doctor becomes the “care manager” Family doctor must make referral to hospitals Make co-pay

4、as defined by payers (office visits, generic / brand name drug, out-of-pocket maximums, etc.),Payers,Government: Medicare and state Medicaid programs Health insurance programs / HMO Patients,What Do Payers Do?,Pay claims submitted by providers. Establish “reasonable and customary” fee schedule. Prov

5、ider contracting based on price and quality. Manage care through pre-authorization, referrals, case management, and preventive care.,People stay healthy Diseases are diagnosed early Minimize disease complications,What benefits health insurance companies,Health Insurance Companies Keep Provider Costs

6、 Down,Physician contracting Hospital contracting Formulary,This 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。,A Private Third Party Payer is the key to keep US Health Care S

7、ystem in Balance,Competition after Privatization,Compete on both price and quality,Medicare and Medicaid,Federal Government is by far the largest payer through Medicare and Medicaid. Medicare is for people 65 years of age and older. Medicare spending will more than double in the next decade, from $3

8、09 billion in 2004 to $792 billion in 2015. Medicaid spending is expected to increase from $293 billion to $670 billion during the same period,Differences between Health Insurance and National Health Plan,Click to add Text Click to add Text Click to add Text,Health insurance companies are private bu

9、siness with P&L responsibilities Adverse selection Pre-existing condition Investment in health improvement,National Health Plan is an entitlement program not subject to above concerns and should be lower cost to implement.,National Health Plan,Health Insurance,Why Do We Need Health Insurance?,High c

10、ost at unpredictable frequency,80-20 rule,Current money for current needs,US Health Care Reform Map,Current US Status High cost High quality for the rich 15% uninsured,National Health Care,Proponents 赞成方 People Businesses Government,Obstacles 阻碍方 Current stakeholders who stand to lose,Timeline of Obama Care,People under 26 can be covered by parents No pre-existing condition for children Life time / annual limits removed No policy cancellation after a person gets ill,Health plans must offer electronic records No pre-existing conditio