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NATIONAL HEALTH EXPENDITURES

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Title: NATIONAL HEALTH EXPENDITURES


1
  • NATIONAL HEALTH EXPENDITURES

2
  • HEALTH CARE SPENDING IN THE UNITED STATES IS
    PROJECTED TO REACH 2.7 TRILLION IN 2011,
  • 4.3 TRILLION IN 2018, UP FROM 1.3 TRILLION IN
    2000.
  • CURRENT SPENDING ABOUT 2.7 TRILLION DOLLARS.

3
Comparison of NHE/GDP
4
  • Some really pretty color charts

5
Percentage of National Health Spending
6
Source of Dollars for National Health Spending
7
Where the money goes
8
Where the money goes - percentage
9
Total National Health Expenditures, 20082017
Projected and Various Scenarios
Dollars in trillions
10
(No Transcript)
11
  • INTERNATIONAL COMPARISON
  • 2009 U.S. SPENT 17.3 OF GDP ON HEALTH
  • GERMANY SPENT 10.7
  • CANADA SPENT 9.7

12
  • GROWTH IN HEALTH CARE SPENDING IN THE UNITED
    STATES IS PROJECTED TO BE 5.7 IN 2009.
  • AVERGE ANNUAL GROWTH IS EXPECTED TO REMAIN THE
    SAME RATE THROUGH 2017.

13
  • AS A PERCENTAGE OF GROSS DOMESTIC PRODUCT (GDP),
    HEALTH CARE SPENDING IS PROJECTED TO INCREASE TO
    17.6 PERCENT IN 2012. IT IS EXPECTED THAT HEALTH
    CARE SPENDING WILL REACH OVER 4.3 TRILLION AND
    BE 19.5 OF GDP. (2007-17)

14
  • THE GROWTH IN PRESCRIPTION DRUG SPENDING IS
    EXPECTED TO DECELERATE FROM 17.3 PERCENT IN 2000
    TO 10.1 PERCENT IN 2011. PRESCRIPTION DRUGS WILL
    STILL REMAIN THE FASTEST GROWING HEALTH SECTOR.

15
  • IN JUST THREE YEARS, THE MEDICARE AND MEDICAID
    PROGRAMS WILL ACCOUNT FOR 50 OF ALL NATIONAL
    HEALTH SPENDING.

16
  • MEDICARES HOSPITAL INSURANCE TRUST FUND IS
    EXPECTED TO PAY OUT MORE IN HOSPITAL BENEFITS
    THAN IT RECEIVES IN TAXES AND OTHER DEDICATED
    REVENUES

17
  • NURSING HOME SPENDING IS PROJECTED TO ACCELERATE
    MORE RAPIDLY THAN PREVIOUSLY ANTICIPATED.

18
  • INSURANCE PREMIUMS FOR EMPLOYER-BASED HEALTH
    INSURANCE ROSE 7.7 IN 2006
  • SMALL EMPLOYERS 8.8
  • BUSINESS WITH LESS THAN 24 EMPLOYEES 10.5

19
  • SINCE 2000 EMPLOYMENT BASED PREMIUMS HAVE
    INCREASED BY 87.
  • IN CONTRAST, INFLATION OVER THE SAME PERIOD
    ACCUMULATED AT 18
  • HEALTH INSURANCE PREMIUMS ARE THE FASTEST GROWING
    COMPONENT FOR EMPLOYERS AND MAY OVERTAKE PROFITS
    BY 2008.

20
  • THE AVERAGE EMPLOYEE CONTRIBUTION TO COMPANY
    BASED HEALTH INSURANCE HAS INCREASED 143 SINCE
    2000.
  • AVERAGE OUT-OF-POCKET COSTS FOR COPAYMENTS AND
    DEDUCTIBLES HAVE INCREASED BY 115 SINCE 2000

21
  • MEDICAL INFLATION WILL INCREASE.

22
  • COMMERCIAL MANAGED CARE WILL SEE SLOWER
    MEMBERSHIP GROWTH AND FEWER MEDICAL CONTROLS
    WHICH WILL CONTRIBUTE TO HIGHER HEALTH CARE
    COSTS.

23
  • AFTER 2002, GOVERNMENT SPENDING WILL ACCELERATE
    AS AGING BABY BOOMERS DEMAND MORE GOVERNMENT
    SUPPORT FOR THEIR CARE.

24
  • THE PRIVATE SECTORS ABILITY TO HOLD DOWN HEALTH
    CARE COSTS THROUGH MANAGED CARE HAS REACHED A
    LIMIT.

25
  • COST SAVINGS FROM MANAGED CARE RESULTED PRIMARILY
    FROM LOWER PAYMENTS TO PROVIDERS, NOT BY
    IMPROVING HEALTH STATUS AND REDUCING UTILIZATION.

26
  • FINANCIAL STRUGGLES EXPERIENCED BY HMOS WILL
    RESULT IN HIGH COSTS FOR HEALTH CARE COVERAGE.

27
  • CONTAINING DRUG COSTS WILL BE ONE OF THE GREATEST
    CHALLENGES THE HEALTH CARE SYSTEM WILL FACE.

28
  • PRESCRIPTION DRUG COSTS WILL CONTINUE TO
    ESCALATE, FUELED BY DIRECT MARKETING TO CONSUMERS
    AND NEW DRUGS TO IMPROVE LIFESTYLE AND ADDRESS
    CHRONIC CONDITIONS OF AN AGING POPULATION.

29
  • THE NEW MEDICARE PRESCRIPTION PLAN HAS BEEN
    INTRODUCED TO THE PUBLIC WITH MIXED REVIEWS. THE
    COST FIGURES PROVIDED ARE SUSPECT. A LARGE
    QUESTION REMAINS ABOUT SENIORS UNDERSTANDING THE
    NEW SYSTEM AND LEARNING HOW TO USE IT.

30
  • RISING HEALTH CARE COSTS REDUCE THE AFFORDABILITY
    OF HEALTH CARE COVERAGE FOR ALL CONSUMERS.

31
  • EMPLOYERS WILL SHIFT MORE OF THE COST OF HEALTH
    CARE TO EMPLOYEES SINCE EMPLOYEES ABILITY TO
    NEGOTIATE LOWER PRICES WITH MANAGED CARE
    COMPANIES WILL BE LIMITED IN LIGHT OF THE
    FINANCIAL LOSSES INCURRED BY THE PLANS.

32
  • SOME EMPLOYERS WILL DECIDE NOT TO OFFER COVERAGE.
    THE END RESULT WILL BE MORE UNINSURED CITIZENS.

33
  • IMPACT OF RISING HEALTH CARE COSTS.
  • PRIMARY REASON PEOPLE DO NOT HAVE HEALTH
    INSURANCE
  • 23 OF THE INSURED REPORT THAT LIFESTYLES HAVE
    BEEN DRAMATICALLY CHANGED DUE TO MEDICAL BILLS.

34
  • ONE IN FOUR AMERICANS HAVE HAD DIFFICULTY IN
    PAYING FOR MEDICAL CARE.
  • 50 OF ALL BANCRUPTCY FILINGS PARTIALLY RESULTANT
    FROM MEDICAL EXPENSES.

35
  • IF ONE MEMBER OF A FAMILY IS UNINSURED AND HAD
    MEDICAL BILLS, IT CAN EFFECT THE ECONOMIC
    STABILITY OF THE WHOLE FAMILY.

36
  • ALL OF THESE PROJECTIONS AND ESTIMATES OF THE
    FUTURE MAY BE CHANGED WITH THE ELECTION OF A NEW
    ADMINISTRATION IN THE NOVEMBER ELECTION OF 2008.
  • STILL UNDER CONSIDERATION AS WE SPEAK

37
  • EXPERTS AGREE THAT OUR HEALTH CARE SYSTEM IS
    RIDDLED WITH INEFFICIENCIES, EXCESSIVE
    ADMINISTRATIVE EXPENSES, HIGH PRICES, POOR
    MANAGEMENT,
  • AND INAPPROPRIATE CARE, WASTE, AND FRAUD.

38
  • End of Presentation for 6th Period Lecture for
    September 24TH 2012
  • QUESTIONS?
  • DISCUSSION?

39
  • MEDICARE IN DETAIL

40
  • MEDICARE IS A FEDERAL HEALTH INSURANCE PROGRAM
    WHICH PROVIDES MEDICAL COVERAGE FOR PEOPLE 65 AND
    OLDER, FOR CERTAIN DISABLED PEOPLE, AND SOME
    PEOPLE WITH END-STATE RENAL DISEASE.

41
  • THE PROGRAM BEGAN IN JULY OF 1966 AND WAS
    ESTABLISHED BY CONGRESS THROUGH TITLE XVIII OF
    THE FEDERAL SOCIAL SECURITY ACT.

42
  • MEDICARE IS MANAGED BY THE CENTERS FOR MEDICARE
    AND MEDICAID SUPPORT (FORMERLY KNOWN AS HCFA),
    WHICH IS A BRANCH OF THE HEALTH AND HUMAN
    SERVICES (HHS) OF THE U.S. FEDERAL GOVERNMENT.

43
  • HOW BIG IS THE MEDICARE PROGRAM?

44
  • IN 2007MEDICARE
  • PROCESSED MORE THAN 900 MILLION CLAIMS

45
  • PAID OUT MORE THAN 330 BILLION IN BENEFITS
  • HAD 42.5 MILLION BENEFICIARIES RECEIVING BENEFITS

46
  • WHAT IS MEDICARE PART A?

47
  • PART A OF THE MEDICARE PROGRAM IS HOSPITAL
    INSURANCE. THIS PROGRAM IS FINANCED BY

48
  • TAXES PAID BY EMPLOYERS AND EMPLOYEES THROUGH THE
    FICA MECHANISM.
  • SELF-EMPLOYED INDIVIDUAL CONTRIBUTIONS.

49
  • RAILROAD WORKERS, THEIR EMPLOYERS THROUGH THE
    RRA.
  • ORGANIZATIONS WHICH ADMINISTER MEDICARE PART A
    ARE CALLED FISCAL INTERMEDIARIES

50
  • PART A COVERAGE HELPS PAY FOR (NOT LIMITED TO)
  • INPATIENT HOSPITAL CARE.
  • INPATIENT CARE IN A SKILLED NURSING FACILITY
    FOLLOWING A COVERED HOSPITAL STAY.

51
  • HOME HEALTH CARE.
  • HOSPICE CARE.

52
  • WHAT IS MEDICARE PART B?

53
  • PART B OF THE MEDICARE PROGRAM IS MEDICAL
    INSURANCE. FINANCING FOR THIS PART OF THE
    PROGRAM IS OBTAINED FROM
  • PREMIUM PAYMENTS BY ENROLLEES.

54
  • OCCASIONAL CONTRIBUTIONS FROM THE FEDERAL
    GOVERNMENT.
  • INTEREST EARNED ON THE PART B TRUST FUND.

55
  • ORGANIZATIONS WHICH ADMINISTER MEDICARE PART B
    ARE CALLED CARRIERS.
  • PART B COVERAGE HELPS TO PAY FOR (NOT LIMITED TO)

56
  • MEDICALLY NECESSARY DOCTORS SERVICES PROVIDED IN
    A VARIETY OF MEDICAL SETTINGS.
  • CHARGES FROM LIMITED LICENCED PRACTITIONERS SUCH
    AS INDEPENDTLY PRACTICING PHYSICAL THERAPISTS,
    ETC.

57
  • WHAT IS MEDICARE PART C?

58
  • A MEDICARE BENEFICIARY MAY CHOOSE TO HAVE COVERED
    ITEMS AND SERVICES FURNISHED TO HIM/HER THROUGH A
    MANAGED CARE PLAN INSTEAD OF THE TRADITIONAL
    MEDICARE PROGRAM.

59
  • MEDICARE-CHOICE OR MEDICARE PART C IS A NEW
    SET OF HEALTH CARE OPTIONS CREATED BY THE
    BALANCED BUDGET ACT OF 1997.

60
  • CHOICES INCLUDE
  • HEALTH MAINTENANCE ORGANIZATIONS (HMO)
  • POINT OF SERVICE (POS) OPTION

61
  • PROVIDER SPONSORED ORGANIZATION (PSO)
  • PREFERRED PROVIDER ORGANIZATION (PPO)

62
  • WHAT IS MEDICARE PART D?
  • Part D is the new prescription benefit provided
    under Medicare. It is very new, and has a
    multiple private insurance plans that are
    involved.

63
  • THE BIG ISSUE IS THE SO-CALLED
  • DOUGHNUT HOLE AND IS AN ISSUE IN THE CURRENT
    REFORM LEGISLATION PROPOSALS.

64
  • WHO IS ELIGIBLE FOR MEDICARE?

65
  • THE AGED 65 YEARS OLD OR OLDER AND IS ELIGIBLE
    FOR MONTHLY SOCIAL SECURITY ALLOTMENTS.

66
  • THE DISABLED ONE IS ENTITLED TO SOCIAL
    SECURITY, RAILROAD RETIREMENT OR OTHER FEDERAL
    PROGRAMS BY VIRTUE OF A DISABILITY.

67
  • THOSE WITH END-STAGE RENAL DISEASE INDIVIDUALS
    WHO RECEIVE DIALYSIS OR A KIDNEY TRANSPLANT FOR
    END-STAGE RENAL DISEASE.

68
  • DO MEDICARE BENEFICIARIES HAVE ANY SPECIAL
    RIGHTS?

69
  • PROTECTION WHEN THEY GET HEALTH CARE SERVICES
  • ASSURED ACCESS TO NEEDED HEALTH CARE SERVICES

70
  • PROTECTION AGAINST UNETHICAL PRACTICES
  • THE RIGHT TO RECEIVE EMERGENCY CARE WITHOUT PRIOR
    APPROVAL

71
  • THE RIGHT TO APPEAL THE ORIGINAL MEDICARE PLANS
    DECISION ABOUT PAYMENT/SERVICES PROVIDED.
  • THE RIGHT TO INFORMATION ABOUT ALL TREATMENT
    OPTIONS.

72
  • THE RIGHT TO KNOW HOW THEIR MEDICARE HEALTH PLAN
    PAYS ITS DOCTORS

73
  • THE BBA OF 1997 GIVES THE BENEFICIARY THE RIGHT
    TO REQUEST AND RECEIVE AN ITEMIZED STATEMENT OF
    SERVICES PERFORMED.

74
  • MEDICAID

75
  • THE MEDICAID PROGRAM IS A JOINT FEDERAL/STATE
    HEALTH PLAN FOR BENEFICIARIES THAT ARE NOT ABLE
    TO FINANCIALLY OBTAIN HEALTH INSURANCE.

76
  • FOR PHYSICIANS WHO ACCEPT MEDICAID ASSIGNMENT,
    THE TOTAL MEDICARE AND MEDICAID PAYMENTS
    REPRESENT PAYMENT IN FULL FOR SERVICES RENDERED.

77
  • REIMBURSEMENT

78
  • IN GENERAL, THE MEDICARE PROGRAM IS DESIGNED ONLY
    TO PROVIDE PAYMENT FOR SERVICES WHICH ARE
    CONSIDERED TO BE MEDICALLY REASONABLE AND
    NECESSARY TO THE OVERALL DIAGNOSIS AND TREATMENT
    OF THE PATIENTS CONDITION.

79
  • FOR EVERY SERVICE BILLED, THE PROVIDER MUST
    INDICATE THE SPECIFIC SIGN, SYMPTOM, OR PATIENT
    COMPLAINT NECESSITATING THE SERVICE.

80
  • ROUTINE/PREVENTATIVE SERVICES ARE GENERALLY
    CONSIDERED SCREENING SERVICES AND ARE NOT COVERED.

81
  • FRAUD AND ABUSE

82
  • THE ESTIMATED COSTS FOR MEDICARE FRAUD EXCEED 33
    BILLION.
  • SOME EXPECT IT TO REACH 70 BILLION.

83
  • THE BILLIONS OF TAXPAYER DOLLARS LOST TO HEALTH
    CARE FRAUD ARE THE FINANCIAL RESOURCES THAT
    SHOULD BE USED TO PAY FOR SERVICES THAT KEEP
    BENEFICIARIES IN GOOD HEALTH.

84
  • THE MEDICARE PROGRAM HAS BECOME BIG BUSINESS AND
    HAS ATTRACTED AS BIG BUSINESSES SOMETIME DO A
    FEW UNSAVORY CHARACTERS TAKE ADVANTAGE.

85
  • IT IS BECOMING VERY IMPORTANT THAT PROVIDERS TO
    BE CAUTIOUS.

86
  • WHAT IS FRAUD?

87
  • FRAUD IS DEFINED AS KNOWINGLY AND WILLFULLY
    EXECUTING, OR ATTEMPTING TO EXECUTE, A SCHEME OR
    ARTIFACE TO DEFRAUD ANY HEALTH CARE BENEFIT
    PROGRAM OR TO OBTAIN BY MEANS OF FALSE AND
    FRAUDULENT PRETENSES, REPRESENTATIONS, OR
    PROMISES, ANY OF THE MONEY OR PROPERTY OWNED BY,
    OR UNDER THE CUSTODY OR CONTROL OF, ANY HEALTH
    CARE BENEFIT PROGRAM.

88
  • EXAMPLES OF FRAUD

89
  • BILLING FOR SERVICES NOT TENDERED
  • SOLICITING, OFFERING, OR RECEIVING A KICKBACK,
    BRIBE, OR REBATE

90
  • USING AN INCORRECT OR INAPPROPRIATE PROVIDER
    NUMBER IN ORDER TO BE PAID (E.G. USING A DECEASED
    PROVIDERS NUMBER)

91
  • SIGNING BLANK RECORDS OR CERTIFICATION FORMS THAT
    ARE USED BY ANOTHER ENTITY TO OBTAIN MEDICARE
    PAYMENT.

92
  • SELLING OR SHARING PATIENTS MEDICARE NUMBERS SO
    FALSE CLAIMS CAN BE FILED.

93
  • FALSIFYING INFORMATION ON APPLICATIONS, MEDICAL
    RECORDS, BILLING STATEMENTS, AND/OR COST REPORTS
    OR ON ANY STATEMENT FILED WITH THE GOVERNMENT

94
  • MISREPRESENTING AS MEDICALLY NECESSARY,
    NON-COVERED SERVICES BY USING INAPPROPRIATE
    PROCEDURE OR DIAGNOSIS CODES.

95
  • WHAT IS ABUSE?

96
  • ABUSE MAY, DIRECTLY OR INDIRECTLY, RESULT IN
    UNNECESSARY COSTS TO THE MEDICARE OR MEDICAID
    PROGRAM, IMPROPER PAYMENT, OR PAYMENT FOR
    SERVICES WHICH FAIL TO MEET PROFESSIONALLY
    RECOGNIZED STANDARDS OF CARE, OR THAT ARE
    MEDICALLY UNNECESSARY.

97
  • EXAMPLES OF ABUSE

98
  • USING PROCEDURE OR REVENUE CODES THAT DESCRIBE
    MORE EXTENSIVE SERVICES THAN THOSE ACTUALLY
    PERFORMED.
  • ROUTINELY SUBMITTING DUPLICATE CLAIMS.

99
  • BILLING FOR SERVICES GROSSLY IN EXCESS OF THOSE
    NEEDED BY PATIENTS

100
  • ACTIONS AGAINST PROVIDERS WHO COMMIT FRAUD OF
    ABUSE

101
  • BECAUSE IT IS A CRIME TO DEFAUD THE UNITED STATES
    GOVERNMENT OR ANY OF ITS PROGRAMS, AN INDIVIDUAL
    MAY BE SENT TO PRISON, FINED OR BOTH.

102
  • CRIMINAL CONVICTIONS USUALLY INCLUDE RESTITUTION
    AND SIGNIFICANT FINES.
  • PROVIDERS MAY LOSE THEIR LICENSES.

103
  • CONVICTION MANDATORILY RESULTS IN EXCLUSION FROM
    MEDICARE AND OTHER FEDERAL HEALTH PROGRAMS FOR A
    SPECIFIC LENGTH OF TIME.

104
  • ACTIONS RESULTING FROM KICKBACKS, BRIBES, FALSE
    STATEMENTS, AND REBATES MAY RESULT IN BEING FOUND
    GUILTY AS A FELON AND UPON CONVICTION BE FINED
    NOT MORE THAN 50,000 PER VIOLATION OR IMPRISONED
    FOR NOT MORE THAN FIVE YEARS PER VIOLATION, OR
    BOTH.

105
  • WELFARE REFORM

106
  • A POLICY ISSUE UNINTENDED CONSEQUENCES OF AS OF
    1997, APPROXIMATELY 675,000 LOW-INCOME PEOPLE HAD
    LOST MEDICAID COVERAGE AND BECOME UNINSURED DUE
    TO WELFARE REFORM.

107
  • IT IS NOW GENERALLY ACCEPTED THAT WELFARE REFORM
    HAS CONTRIBUTED TO THE GROWTH IN THE NUMBER OF
    AMERICANS WITHOUT HEALTH INSURANCE.

108
  • CHILDREN ACCOUNT FOR TWO-THIRDS OF THOSE WHO LOST
    MEDICAID COVERAGE DUE TO WELFARE REFORM.

109
  • THE DECLINE IN CHILDRENS INSURANCE COVERAGE,
    HOWEVER, HAS BEEN OFFSET TO SOME EXTENT BY THE
    IMPLEMENTATION OF THE CHILDRENS HEALTH INSURANCE
    PROGRAM IN SOME STATES.

110
  • PARENTS WHO HAVE MOVED FROM WELFARE TO WORK OFTEN
    HAVE JOBS THAT DO NOT PROVIDE COVERAGE OR HAVE
    INCOMES SO LOW THAT THEY ARE UNABLE TO PURCHASE
    THEIR OWN COVERAGE.
  • THIS REMAINS A PROBLEM.

111
  • MEDICARE SOLVENCY
  • MEDICARE TRUSTEES MEDICARE WILL BE BANKRUPE IN
    THE YEAR 2041 AT WHICH POINT IT WILL BE ABLE TO
    PAY ONLY ABOUT 75 OF PROMISED BENEFITS

112
  • END OF LECTURE FOR September 26th, 2012 6th
    Period Lecture
  • QUESTIONS?
  • DISCUSSION?

113
HEALTH INSURANCE
114
  • Add slide from Health 2000

115
  • HEALTH INSURANCE PROVIDES PEOPLE WITH A WAY TO
    PROTECT THEMSELVES AGAINST FINANCIAL CATASTROPHE
    AND TO ASSURE THEMSELVES AND THEIR FAMILIES OF
    ACCESS TO THE HEALTH CARE SYSTEM.

116
  • PRIVATE INSURANCE COMPANIES DETERMINE PREMIUMS
    THROUGH ACTUARIAL ASSESSMENTS OF THE RISK
    ASSOCIATED WITH THE INSURED GROUP.

117
  • RISING HEALTH CARE COSTS CONTINUE TO BE THE MOST
    PRESSING PROBLEM OF THE HEALTH CARE SYSTEM.

118
  • MOST COMMERCIAL HEALTH INSURANCE COMPANIES
    PROVIDE TWO BASIC CATEGORIES OF COVERAGE
  • MEDICAL EXPENSE INSURANCE AND DISABILITY INCOME
    INSURANCE.

119
  • MEDICAL EXPENSE INSURANCE PROVIDES BROAD BENEFITS
    THAT CAN COVER VIRTUALLY ALL EXPENSES CONNECTED
    WITH HOSPITAL AND MEDICAL CARE AND RELATED
    SERVICES.

120
  • DISABILITY INCOME INSURANCE PROVIDES PERIODIC
    PAYMENTS WHEN THE INSURED IS UNABLE TO WORK AS A
    RESULT OF SICKNESS OR INJURY.

121
  • PLANS ADMINISTERED BY EMPLOYERS, LABOR

122
  • HMO IS BOTH THE INSURER AND PROVIDER IN BEING
    OBLIGATED TO FURNISH NEEDED CARE AS SPECIFIED IN
    THE SUBSRIBERS CONTRACT.

123
  • SELF-INSURANCE PLAYS AN IMPORTANT ROLE IN THE
    PRIVATE COVERAGE SYSTEM. EMPLOYERS, NOT
    INSURERS, ASSUME THE RISK.

124
  • UNIONS, FRATERNAL SOCIETIES, COMMUNITIES, AND BY
    RURAL AND CONSUMER HEALTH COOPERATIVES OFTEN MAKE
    INSURANCE AVAILABLE TO SPECIFIC GROUPS OF PEOPLE
    WHO ARE NOT COVERED UNDER CONVENTIONAL PLANS.

125
  • PRIVATE HEALTH INSURANCE

126
  • HOSPITAL/MEDICAL INSURANCE
  • HOSPITAL EXPENSE COVERAGE PROVIDES SPECIFIC
    BENEFITS FOR DAILY HOSPITAL ROOM AND BOARD AND
    USUAL HOSPITAL SERVICES AND SUPPLIES DURING
    HOSPITAL CONFINEMENT.

127
  • MAJOR MEDICAL EXPENSE INSURANCE
  • MAJOR MEDICAL COVERAGE OFFERS BROAD AND
    SUBSTANTIAL PROTECTION FOR LARGE, UNPREDICTABLE
    MEDICAL EXPENSES. IT COVERS A WIDE RANGE OF
    MEDICAL CHARGES WITH FEW INTERNAL LIMITS AND A
    HIGH OVERALL MAXIMUM BENEFIT.

128
  • MEDICARE SUPPLEMENT POLICY
  • MEDICARE SUPPLEMENTAL INSURANCE, OFTEN REFERRED
    TO AS A MEDIGAP OR MEDSUP POLICY, IS ACCIDENT
    AND SICKNESS INSURANCE DESIGNED PRIMARILY AS A
    SUPPLEMENT FOR HOSPITAL, MEDICAL, OR SURGICAL
    EXPENSES FOR PERSONS COVERED BY MEDICARE.

129
  • DISABILITY INCOME INSURANCE
  • DISABILITY INCOME COVERAGE REPLACES INCOME LOST
    BY AN EMPLOYEE WHEN INJURY OR ILLNESS PREVENTS
    THE INDIVIDUAL FROM WORKING.

130
  • DENTAL EXPENSE INSURANCE
  • DENTAL EXPENSE INSURANCE REIMBURSES FOR EXPENSES
    OF DENTAL SERVICES AND SUPPLIES AND ENCOURAGES
    PREVENTATIVE CARE.

131
  • PLANS NORMALLY INCLUDE SUBSTANTIAL CONSUMER
    COPAYMENTS, ALTHOUGH COPAYMENTS MAY BE LOWER FOR
    PREVENTATIVE SERVICES.

132
  • LONG TERM CARE INSURANCE
  • LONG TERM CARE INSURANCE CONTINUES BROAD-RANGED
    MAINTENANCE AND HEALTH SERVICES TO THE
    CHRONICALLY ILL OR DISABLED.

133
HIPAA
  • The Health Insurance Portability and
    Accountability Act of 1996

134
  • GOALS AND OBJECTIVES OF HIPAA.
  • 1. Streamline industry inefficiencies
  • 2. Detect and prosecute fraud
  • 3. Reduce paperwork
  • 4. Enable workers to change jobs even with
    pre-existing medical conditions

135
  • 2. Reduce healthcare fraud and abuse
  • 3. Enforce standards for health information
  • 4. Guarantee security and privacy of health
    information

136
  • HIPAA Organization
  • TITLE I
  • Guarantees health insurance access, portability
    and renewal.
  • Guarantees coverage and renewal
  • Eliminates some pre-existing condition exclusions
  • Prohibits discrimination based on health status.

137
  • TITLE II
  • Preventing healthcare fraud and abuse
  • Fraud and abuse controls
  • Administration Simplification (AS)
  • Medical Liability Reform

138
  • TITLE III
  • Medical Savings Accounts
  • Health Insurance tax deduction for self-employed

139
  • TITLE IV
  • Enforcement of group health plan provisions

140
  • TITLE V
  • Revenue offset provisions

141
  • Rules that have been implemented
  • Standards for privacy of individually
    identifiable Health Information
  • National Provider identifier
  • Employer identifier
  • Security and Electronic Signatures

142
  • National Individual Identifier
  • Has run afoul of protests from citizens about
    big brother having the ability to infringe on
    the privacy of the individual

143
  • PROTECTING THE PRIVACY OF PATIENTS HEALTH
    INFORMATION
  • Access to Medical Records
  • Notice of Privacy Practices
  • Limits on the Use of Personal Medical Information

144
The government is watching you!
145
  • THE BLUES
  • A LITTLE BIT OF HISTORY

146
  • THE EARLY DAYS OF BLUE CROSS AND BLUE SHIELD MARK
    THE BIRTH OF PREPAID HEALTH CARE COVERAGE IN
    AMERICA.

147
  • BLUE SHIELD PLANS WERE ESTABLISHED TO COVER
    PHYSICIANS SERVICES.

148
  • NOW, BOTH BRANDS REPRESENT THE FULL SPECTRUM OF
    HEALTH CARE COVERAGE.

149
  • IN NEARLY EVERY STATE, BCBS PLANS HAVE EVOLVED
    INTO SINGLE CORPORATIONS OR COOPERATE CLOSELY.
    IN A FEW LOCATIONS, THEY REMAIN SEPARATE
    OPERATIONS.

150
  • THE BLUE SYSTEM IS A FEDERATION OF 43
    INDEPENDENT LOCALLY OPERATED PLANS UNITED THROUGH
    MEMBERSHIP IN THE BLUE CROSS AND BLUE SHIELD
    ASSOCIATION.

151
  • THE 81.5 MILLION AMERICANS SERVED BY BLUE PLANS
    REPRESENT 28.6 PERCENT OF THE U.S. POPULATION.

152
  • BLUE PLANS OFFER HEALTH INSURANCE COVERAGE IN ALL
    50 STATES, THE DISTRICT OF COLUMBIA AND PUERTO
    RICO.
  • THE BLUES COVER ALL SEGMENTS OF THE POPULATION,
    INCLUDING LARGE EMPLOYER GROUPS, SMALL
    BUSINESSES, INDIVIDUAL CONSUMERS AND THEIR
    FAMILIES.

153
  • MORE THAN 80 PERCENT OF U.S. HOSPITALS AND
    NEARLY 100 PERCENT OF U.S. PHYSICIANS ACCEPT BLUE
    CROSS AND BLUE SHIELD CARDS.

154
  • MORE THAN ¾ OF FORTUNE 100 COMPANIES AND ½ OF
    ALL FORTUNE 500 COMPANIES OFFER BLUE CROSS AND
    BLUE SHIELD TO THEIR EMPLOYEES.

155
  • BLUE PLANS COLLECTIVELY PAY 111 BILLION IN
    CLAIMS EACH YEAR.

156
  • KEY INITIATIVES
  • FEP FEDERAL EMPLOYEE PROGRAM..THE LARGEST
    PRIVATELY UNDERWRITTEN HEALTH INSURANCE CONTRACT
    IN THE WORLD ENROLLS 4 MILLION FEDERAL
    EMPLOYEES, RETIREES, AND THEIR FAMILIES.

157
  • MEDICARE IS THE LARGEST SINGLE PROCESSOR OF
    MEDICARE CLAIMS HANDLING MORE THAN 90 PER CENT
    OF ALL CLAIMS FROM HOSPITALS AND INSTITUTIONS
    (PART A) AND NEARLY 60 PERCENT OF CLAIMS FROM
    PHYSICIANS AND OTHERS (PART B)

158
  • TEC TECHNOLOGY EVALUATION CENTER EXAMINES THE
    BEST SCIENTIFIC EVIDENCE TO DETERMINE THE SAFETY
    AND EFFICACY OF NEW MEDICAL PRODUCURES, DEVICES ,
    AND TECHNOLOGIES.

159
  • BLUE CROSS ROOTS

160
  • IN 1929, AN OFFICIAL AT BAYLOR UNIVERSITY IN
    DALLAS INTRODUCED A PLAN TO GUARANTEE SCHOOL
    TEACHERS 21 DAYS OF HOSPITAL CARE FOR 6 A YEAR.

161
  • OTHERS FOLLOWED WITH SIMILAR PLANS.
  • IN 1933, A PLAN IN MINNESOTO BEGAN TO USE THE
    BLUE COLORED CROSS TO IDENTIFY THE HOSPITAL CARE
    PROGRAM.

162
  • BY 1939, THE BLUE CROSS SYMBOL WAS OFFICIALLY
    ADOPTED BY A COMMISSION OF THE AMERICAN HOSPITAL
    ASSOCIATION AS THE NATIONAL EMBLEM FOR PLANS THAT
    MET CERTAIN GUIDELINES.

163
  • IN 1960, THE COMMISSION WAS REPLACED BY THE BLUE
    CROSS ASSOCIATION, WHICH WAS INDEPENDENT OF THE
    AMERICAN HOSPITAL ASSOCIATION.

164
  • THE BLUE SHIELD CONCEPT GREW OUT OF THE LUMBER
    AND MINING CAMPS OF THE PACIFIC NORTHWEST AT THE
    TURN OF THE CENTURY.

165
  • EMPLOYERS MADE ARRANGEMENTS WITH PHYSICIANS WHO
    WERE PAID A MONTHLY FEE FOR THEIR SERVICES.

166
  • THESE CONTRACTS LED TO THE CREATION OF MEDICAL
    SERVICE BUREAUS COMPOSED OF GROUPS OF
    PHYSICIANS.

167
  • THE FIRST WAS ORGANIZED IN 1917 IN TACOMA,
    WASHINGTON.

168
  • THESE PIONEER PROGRAMS PROVIDED THE BASIS FOR THE
    FIRST MODERN BLUE SHIELD PLAN WHICH WAS FOUNDED
    IN CALIFORNIA IN 1939.

169
  • IN 1948, THE BLUE SHIELD WAS REGISTERED AS A
    TRADEMARK.
  • IN 1982, THE BLUE CROSS BLUE SHIELD ASSOCIATION
    WAS CREATED AS THE RESULT OF THE TWO PLANS.

170
  • AND HOW BIG IS BLUE CROSS BLUE SHIELD?

171
  • TOGETHER, 47 INDEPENDENT BLUE AND BLUE SHIELD
    MEMBER PLANS MAKE UP THE BLUE CROSS BLUE SHIELD
    SYSTEM.

172
  • THIS SYSTEM IS COORDINATED BY THE BLUE CROSS BLUE
    SHIELD ASSOCIATION, HOWEVER, ALL MEMBER PLANS
    FUNCTION AS INDEPENDENT, LOCALLY OPERATED
    COMPANIES.

173
  • COLLECTIVELY, BLUE CROSS AND BLUE SHIELD PLANS
    PROVIDE HEALTH CARE COVERAGE FOR 75 MILLION
    PEOPLE IN THE 50 STATES, THE DISTRICT OF COLUMBIA
    AND PUERTO RICO.

174
  • THIS REPRESENTS 27 OF THE US POPULATION.
  • BLUE CROSS AND BLUE SHIELD ASSOCIATION, WITH
    HEADQUARTERS IN CHICAGO, HAS APPROXIMATELY 800
    EMPLOYEES.

175
  • THE MEMBER PLANS HAVE 150,000 EMPLOYEES
    NATIONWIDE, MAKING THE BLUES COLLECTIVELY THE
    19TH LARGEST EMPLOYER IN THE UNITED STATES.

176
  • THE BLUE CROSS AND BLUE SHIELD PLANS AND THEIR
    SUBSIDIARIES COLLECTIVELY REPORTED REVENUE OF
    97.3 BILLION FOR THE YEAR ENDED DECEMBER 31,
    1999.

177
  • WHILE COSTS FOR OPERATING COMMERCIAL INSURANCE
    CAN RUN AS HIGH AS 25 PERCENT, COLLECTIVELY,
    THESE BLUE CROSS AND BLUE SHIELDS PLANS
    ADMINISTRATIVE COSTS AVERAGE 11.9 PERCENT AS OF
    DECEMBER 31, 1999.

178
  • COLLECTIVELY, BLUE CROSS AND BLUE SHIELD PLANS
    COMPRISE THE NATIONS LARGEST PROVIDER OF MANAGED
    CARE SERVICES. MORE THAN 52 MILLIONS PEOPLE
    ROUGHLY 1 IN 6 AMERICANS ARE ENROLLED IN A BLUE
    CROSS AND BLUE SHIELD MANAGED CARE PLAN.

179
  • BLUE CROSS AND BLUE SHIELD MEDICARE CONTRACTORS
    ARE COLLECTIVELY THE LARGEST PROCESSOR MEDICARE
    CLAIMS. IN 1999, BLUE COMPANIES PAID 135
    BILLION IN BENEFIT PAYMENTS ON BEHALF OF THE
    PROGRAMS BENEFICIARIES.

180
  • IN FY 99, BLUE CROSS AND BLUE SHIELD MEDICARE
    CONTRACTORS PROCESSED 89 PER CENT OF THE CLAIMS
    FROM HOSPITALS AND OTHER PROVIDER INSTITUTIONS
    (PART A) AND 59 PERCENT OF THE CLAIMS FROM
    PHYSICIANS AND OTHER HEALTH CARE PRACTITIONERS
    (PART B).

181
  • THE ADMINISTRATION OF MEDICARE IS THE NATIONS
    MOST SUCCESSFUL PARTNERSHIP BETWEEN PRIVATE
    INDUSTRY AND THE GOVERNMENT. BLUE PLANS HAVE
    BEEN PROCESSORS SINCE THE INCEPTION OF MEDICARE
    IN 1966, MARKING 30-PLUS YEARS OF SERVICE TO
    MEDICARE BENEFICIARIES.

182
  • END OF LECTURE FOR September 26th , 2012, 7th
    Period.
  • QUESTIONS?
  • DISCUSSION?
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