The evolution of the health care system

April 5, 2018 | Author: Anonymous | Category: Business
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1. The Evolution of the HealthCare System Robin Cleeland, Ph.D., LCSW 2. English Poor Law Tradition Bias against federal and state action inregard to social welfare. Adopted English poor law tradition. Only local gov’t has the authority, right,and obligation to provide benefits. Benefits are provided to the “deservingpoor.” 3. Local Government Initiatives Local governments did engage in somepublic health initiatives in the 18th, 19thand early 20th centuries. Built public hospitals and public healthclinics. Created health codes Minimal in nature and directed toward theaged, disabled and deserving poor. 4. Health Care w/o Government Most people received health care at home. Traditional healers. Midwives. Faith healers. Herbalists. Doctors existed but were not like today. 5. The Rise of Physicians and Hospitals State became involved in regulating thesale of potions, herbs, and medicines. Physicians were recognized by stateregulators as “providers of choice.” From late 1800’s to early 1900’s, hospitalstook a central role. 6. Hospitals Prior to the late 1800’s, the nation hadfew hospitals. Hospitals that existed in U.S. were usuallyrun by local counties or charitableorganizations. Hospitals almost exclusively served thepoor, indigent, aged, and disabled. Poor conditions for poor people. 7. Factors that Changed Hospitals The technology of medicine changed. The nursing profession changed. The U.S. became more urban andindustrialized. Hospitals developed new means oftreating people. Medical education changed. (Flexner) 8. Changes in Hospitals As a result of all of these factors, therewas a dramatic rise in the number ofhospitals during the 20th century. In 1873, the U.S. had approximately 178hospitals. By 1900, the number hadreached 4,000. By 1930, the U.S. had7,000 hospitals 9. Hill-Burton The Hill-Burton Program, enacted in 1946,provided federal dollars for communitiesto build hospitals around the country. The program represented the federalgovernment’s first substantial contributionto the health-care system. The goal was to establish a hospital inevery community in the U.S. 10. The Cost of Health Care With the growing number of hospitals andthe increasingly sohisticated medicalprecedures, came and increase in the costof health care. At the same time, the ability of patients topay was declining—particularly during theGreat Depression. 11. Paying for Health Care Hospital administrators ere concernedabout how to support their new facilities. Pre-pay agreements began in the 1920’sand allowed hospitals to enter agreementswith employers if they paid a set fee forevery employee in advance. Hospitals, employers, and consumers wereunhappy with this model. 12. The Birth of the Blues The American Hospital Association enteredinto talks with state regulators to create anew kind of insurance plan based on third-party payers. The regulators insisted that the plans benon-profit. Blue Cross and Blue Shield were born. 13. Government Encourages the Third- Party System The U.S. retained its limited governmentphilosophy. However, insurers, providers, and employers allaccepted help from the government. Govt. made health insurance tax deductible. Health insurance was exempt from the wagefreeze during WW II. 14. Commercial Insurance Commercial companies wanted to share thesuccess of BC/BS. Targeted healthy people. Charged lower premiums that BC/BS. The government encouraged the competition. As a result there was a tremendous growth inemployer-sponsored private insurance. In 1988, more than 140 million Americans hadprivate health insurance. 15. The New Deal Roosevelt sought to use the governmentto save the economy and provide healthcare. He wanted national health insurance, butthe AMA was opposed. Roosevelt compromised and created awelfare system that includes a social-insurance wing and a welfare wing. 16. Hospital Insurance for the Aged Truman proposed national healthinsurance, but lost. The American view has been that healthcare is not a right; it is a benefitpurchasable by those who can afford it. Truman proposed hospital insurance forthe aged and lost. 17. Medicare and Medicaid LBJ won the presidential election in alandslide and had a democratic majority inCongress. For the first time since FDR, the Congresshad the ability, the votes, and the powerto enact comprehensive health legislation. Johnson decided to propose healthinsurance for the aged. 18. As a result of a compromise: Johnson’s proposal for hospital insurancewas enacted as Medicare Part A. The Republican proposal for physicianinsurance for the aged became MedicarePart B. The AMA proposal to expand welfare-medicine became Medicaid. 19. Community Health Centers The program, enacted in 1965, establishedcommunity centers that were clinic-based andoriented toward primary and preventive care. The model sought to allow local groups todevelop their own kinds of health careprograms. These centers were initially funded by thefederal government and later by Medicaid. 20. Medicaid Enacted in 1965 Funded jointly by federal and stategovernments. In 200, Medicaid provided healthinsurance to 40 million low-incomeAmericans at a cost of approx. $200 billiona year. 21. Roots of Managed Care Prepaid health care existed in the 19thcentury, but most providers opposed it. Uncomfortable with prepayment. Providers who took prepayment riskedbearing some of the expenses associatedwith treating consumers who have highcosts.21 22. Problems with the Traditional SystemBy the 1960s and 1970s, there were 3 majorproblems with the traditional system:-rising costs-variations in care-uncoordinated care 23. The Rise of Managed Care Capitated prepaid system—the incentive isto provide less care instead of more. By directly hiring physicians, prepaid planscan reduce physician autonomy—createpractice guidelines. Instituted gatekeeper systems. 24. Problems with Managed Care Patients may lose ability to choose anydoctor. Physicians resisted loss of autonomy. Changed fiscal incentives. 25. The Government and ManagedCare Congress passed the HMO Act of 1973which set aside federal money to helpspur the growth of HMOs around thecountry and required large employers tooffer their employees and HMO option. This was an attempt to deal with thehealth care crisis. 26. The Crisis Continues Americans were not ready for HMOs in1973. By the mid-1980s, large employers startedto complain that they were spending toomuch money on health care and startedlooking at managed care for a solution. 27. IRA’s and PPO’s HMOs were unpopular because consumerscouldn’t choose their doctors. IRAs (independent practice associations) gavepatients ability to choose from an approved listof MDs and see them in their own offices. POSs allowed consumers to see a doctor outsideof the approved list for a higher fee. 28. Managed Care Grows During the 1990’s, managed careexperienced phenomenal growth. Managed-care plans became looser in anattempt to satisfy consumer demands forchoice and physician demands forautonomy. Rising costs are again creating a crisis formanaged care. 29. Legislating Managed Care Bind between pleasing consumers andmanaging costs. Patient protection laws. Employers choose to self-insure to avoidlegislation. 30. Suing HMOs 80%-85% of Americans belong to health planthat prohibits them from bringing to state courta claim for wrongful denial of coverage. Most people have to bring the claim to federalcourt where the awards would be smaller. Pres. Bush wants to limit awards to $500,000total. Advocates argue that the threat of litigationcreates accountability. 31. Questions for DebateIs health care a right?Should the U.S. have national healthinsurance?Should there be caps on medical malpracticeawards?Does managed care work?What is the responsibility of Americans forlimiting health care costs?


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