Health Care Systems and Policy

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Chapter 9
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• Health Care Systems and Policy

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Introduction

• In 2000, Americans spent more than 1.2 trillion
  for health care which represents over 13 of the
  gross national product
• This amount exceeds the average amount spent by
  any other industrialized country

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Introduction

• Public policy is attempting to direct our medical
  system toward health promotion although Medicaid
  and Medicare and other major third-party payers
  offer limited reimbursement for preventive
  procedures
• Many studies show that early detection and
  intervention, immunization, and behavior change
  could significantly reduce many of the leading
  causes of death and disability

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An Overview of the Health Care Industry

• Two general categories of health insurance in the
  United States
• Private
• Traditional fee-for-service
• Group contract
• Public
• Medicare
• Medicaid
• State Childrens Health Insurance Program

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Private Insurance

• Approximately 70.2 of Americans have private
  insurance
• Private insurance can be in the form of
  traditional fee-for-service insurance or group
  contract insurance

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Private Insurance

• Traditional Fee-for-Service Plans
• Include a billing system - the provider charges a
  fee for each service rendered
• Critics of this plan claim that they encourage
  physicians to provide more services than
  necessary
• Proponents prefer the greater flexibility and
  unrestricted access to physicians, tests,
  hospitals, and treatments

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Private Insurance

• Group Contract Insurance
• Managed-care systems, - prepaid group practice
  plans that offer health care services through
  groups of medical practitioners
• HMOs
• PPOs
• The goal of managed care is improved quality of
  care with decreased cost
• 91 of employees with health insurance were
  enrolled in managed-care plans in 1999

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HMOs PPOs

• Company negotiates with specific doctors,
  hospitals, and clinics
• These providers must be used by the employee for
  the reduced fees

• Employer provides a list of participating
  providers
• Employees can choose the physician they want to
  see instead of being solely restricted to the HMO
  providers

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Private Insurance Group Contract Insurance

• In some HMOs, provider receives a capitation
  payment
• Capitation payment A predetermined fee paid per
  enrollee per month to the provider

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Public Insurance

• Medicare and Medicaid
• State Childrens Health Insurance Program
• CHIP

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The Medicare Program

• Medicare is the largest health care insurer in
  the U.S.
• It is designed to assist
• People 65 and older
• People of any age with end-stage renal disease
• People eligible for Social Security disability
  payment programs for more than 2 years
• Qualified railroad retirement beneficiaries and
  merchant seamen

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The Medicare Program

• Medicare consists of two separate parts
• Hospital insurance (Part A)
• Medical insurance (Part B)

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The Medicare Program

• Medicare Part A
• Provides hospital insurance benefits that include
  up to 90 days of inpatient care annually with a
  20 percent coinsurance fee
• Hospital inpatient charges are reimbursed
  according to prospective payment system known as
  diagnosis related groups (DRGs)

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The Medicare Program

• Medicare Part B
• An optional insurance program financed through
  premiums paid by enrollees and contributions from
  federal funds
• Enrolled Medicare Medical Nutrition Therapy (MNT)
  providers are able to bill Medicare for MNT
  services provided to beneficiaries with type 1,
  type 2, and gestational diabetes, nondialysis
  kidney disease, and post-kidney transplants

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The Medicaid Program

• Medicaid is a joint state and federal program
  that provides assistance with medical care for
• Eligible, low-income persons
• Certain low-income pregnant women and children
• The aged, blind, and people with disabilities
• Members of families with dependent children in
  which one parent is absent, incapacitated, or
  unemployed

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The Medicaid Program

• The individual states define eligibility,
  benefits, and payment schedules
• Typically, one must meet three criteria
• Income
• Categorical
• Resource

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The Medicaid Program

• Medicaid covers a variety of services and
  settings, including inpatient and outpatient
  hospital services, physicians services, skilled
  nursing home and home health services, and
  laboratory and x-ray tests
• To date, 36 state Medicaid programs cover certain
  forms of nutrition services provided by dietitians

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The State Childrens Health Insurance Program

• The State Childrens Health Insurance Program
  (SCHIP) is the largest single expansion of health
  insurance coverage for children in more than 30
  years
• States have flexibility in targeting eligible
  uninsured children
• Many of the children served come from working
  families with incomes too high to qualify for
  Medicaid but too low to afford private health
  insurance

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SCHIP Enrollment,1999-2003
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The Uninsured

• The uninsured include the working poor and those
  who work for small businesses
• The employed uninsured number 15 million

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The Uninsured

• The non-working uninsured number 9 million and
  include
• The homeless
• Some deinstitutionalized mentally ill patients
• Low-income people who do not qualify for Medicaid

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of U.S. Persons without Health Care Coverage,
2003
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Demographic Trends and Health Care

• By the year 2030, the baby boom will become a
  senior boom with 21 percent of the population
  over 65 years of age
• Racial and geographical factors in the population
  are also important to the shape of the future

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The Need for Health Care Reform

• Health care reform refers to the efforts
  undertaken to ensure that everyone in the U.S.
  has access to quality health care at an
  affordable price

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The Need for Health Care Reform

• Some of the challenges of health care reform
  include
• Making health care accessible to everyone
• Containing costs
• Providing nursing home care to those who need it
• Ensuring that Medicare and Medicaid can serve all
  who are eligible

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The Need for Health Care Reform

• Cost, access, and quality are interrelated and
  manipulating one has an astounding impact on the
  others
• Health care policy makers are studying
  alternative models of delivery and financing in
  hopes of applying other nations successes to the
  U.S.

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The High Cost of Health Care

• Health care inflation is well established and the
  level of health care activity is expected to grow
  as a result of various factors including
• An aging population
• Increased demand
• Continuing advances in medicine

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National Health Expenditures (Billions of Dollars)
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The High Cost of Health Care

• Major contributors to health care expenditures in
  the U.S. are
• The administrative cost of the insurance process
  itself
• Professional liability costs

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The Nations Health Dollar, 2002
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The High Cost of Health Care

• Efforts at Cost Containment
• Efforts to curb soaring health care costs cover a
  broad spectrum...
• from slowing hospital construction
• to reducing length of hospital stays, and
• and increasing co-payments and deductibles for
  insured employees and Medicare recipients

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The High Cost of Health Care - Cost Containment

• One example of cost containment is the
  prospective payment system (PPS) that the federal
  government implemented
• The purpose of the PPS was to change the behavior
  of health care providers by changing incentives
  under which care is provided and reimbursed

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The High Cost of Health Care - Cost Containment

• PPS (continued)
• Prospective payment means knowing the amount of
  payment in advance
• PPS uses diagnosis related groups (DRGs) as a
  basis for reimbursement
• Patients are classified according to the
  principal diagnosis, secondary diagnosis, sex,
  age, and surgical procedures

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The High Cost of Health Care - Cost Containment

• PPS (continued)
• There are 23 categories and a total of 490 DRGs
• One consequence of PPS has been an increased
  focus on outpatient services

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The High Cost of Health Care

• Equity and Access as Issues in Health Care
• Public opinion polls in the U.S. reveal that most
  people believe all citizens are entitled to
  access to health care...
• but debate continues about the acceptable level
  of health care and what benefits should be
  included

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The High Cost of Health Care Equity and Access

• Racial and Ethnic Disparities in Health
• A recent report released by DHHS shows
  significant improvements in the health of racial
  and ethnic minorities but also indicates that
  important disparities in health persist

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Health Care Reform in the United States

• Almost all industrialized countries except the
  U.S. have national health care programs
• In these systems, coverage is generally universal
  and uniform and costs are paid entirely from tax
  revenues or by some combination of individual and
  employer premiums and government subsidization

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Health Care Reform in the United States

• Health care reform in the U.S. raises a
  formidable list of issues including
• Overall cost containment
• Universal access
• Emphasis on prevention
• Reduction in administrative superstructure and
  costs

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Health Care Reform in the United States

• While the government remains undecided on what
  kind of health care system is needed or how to
  pay for it, health care reform is evolving at an
  accelerating rate without legislation

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Nutrition as a Component of Health Care Reform

• Many believe that nutrition services are the
  cornerstone of cost-effective prevention and are
  essential to halting the spiraling cost of health
  care

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Nutrition as a Component of Health Care Reform

• The American Dietetic Association (ADA) has urged
  that nutrition services be included in any health
  care reform legislation
• Registered dietitians also need to be recognized
  as the nutrition experts of the health care team

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Nutrition as a Component of Health Care Reform

• Cost-Effectiveness of Nutrition Services
• ADA encourages all of its practitioners to
  document the cost-effectiveness of nutrition
  services
• Cost-effectiveness studies compare the costs of
  providing health care against a desirable change
  in patient health outcomes

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Nutrition as a Component of Health Care Reform

• Cost-Effectiveness (continued)
• Effective nutrition therapy can produce economic
  benefits as a result of altered food habits and
  risk factors
• Practice guidelines or protocols that clearly
  specify appropriate care and acceptable limits of
  care for each disease state or condition are
  important to enhance the quality, efficiency, and
  effectiveness of the health care system

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Nutrition as a Component of Health Care Reform

• Care delivered according to a protocol has been
  linked with positive outcomes for the client
• Examples of outcomes include
• Measure of control (serum lipid profiles)
• Quality of life
• Dietary intake
• Patient satisfaction

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Measurable Outcomes of Nutrition Intervention
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Nutrition as a Component of Health Care Reform

• Developing standardized protocols of care for
  nutrition intervention is considered a must for
  achieving payment for nutrition services and
  expanding current levels of third-party
  reimbursement

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Medical Nutrition Therapy and Medicare Reform

• The ADA believes that reimbursement for nutrition
  services through Medicare and Medicaid is
  inadequate
• ADA supports the inclusion of medical nutrition
  therapy as a covered benefit in all types of
  health care delivery

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Medical Nutrition Therapy Providing Return on
Investment

• Oxford Health Plan
• Saved 10 for every 1 spent on nutrition
  counseling for at-risk elderly patients
• The Lewin Group
• 8.6 reduction in hospital utilization for
  patients with CVD
• 16.9 reduction in physician visits for patients
  with CVD
• 9.5 reduction in hospital utilization for
  diabetes patients
• 23.5 reduction in physician visits for diabetes
  patients

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Medical Nutrition Therapy Providing Return on
Investment

• University of California Irvine
• Lipid drug eligibility was obviated in 34 of 67
  subjects
• Estimated annual cost savings from the avoidance
  of lipid medication was 60,652
• Pfizer Corporation
• Projected 728,772 annual savings from reduced
  cardiac claims
• U.S. Department of Defense
• Saved 3.1 million the first year for CVD patients

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Evaluating Nutrition Risk in Older Adults

• NSI DETERMINE Checklist - a nutrition screening
  tool to help identify warning signs of potential
  nutrition problems

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Evaluating Nutrition Risk in Older Adults

• Determine Your Nutritional Health Checklist
• I have an illness or condition that made me
  change the kind or amount of food I eat
• I eat fewer than two meals each day
• I eat few fruits or vegetables or milk products
• I have three or more alcoholic drinks almost
  every day
• I have tooth or mouth problems that make it hard
  for me to eat

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Evaluating Nutrition Risk in Older Adults

• Determine Your Nutritional Health Checklist
  (continued)
• I dont always have enough money to buy the food
  I need
• I eat alone most of the time
• I take three or more different prescribed or
  over-the-counter medicines a day
• Without wanting to do so, I have lost or gained
  10 pounds in the last 6 months
• I am not always physically able to shop, cook,
  and/or feed myself

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Evaluating Nutrition Risk in Older Adults

• Campaign Long-Term Nutrition Risk Reduction
• Demonstrates how nutrition screening and case
  management can help lower nutrition risk among
  frail, homebound older adults

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Evaluating Nutrition Risk in Older Adults

• Goals and Objectives
• Improve the nutritional status of frail,
  homebound older adults receiving home services
  under the Medicaid Waiver Program by
• Nutritionally screening clients
• Providing home-based medical nutrition therapy
  where indicated
• Using a coordinated case management approach to
  determine need for further services
• Evaluating the effectiveness of home-based
  medical nutrition therapy

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Evaluating Nutrition Risk in Older Adults

• Methodology
• Older adults contacted to complete "Nutrition
  Screening Checklist"
• Clients identified as at risk referred for for
  an initial home visit and in-depth nutritional
  assessment
• MNT care plan devised and carried out
• In-depth nutritional assessment repeated at
  discharge

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Evaluating Nutrition Risk in Older Adults

• Results
• Semiannual samplings of 20 of all discharged
  patients
• 89 of clients surveyed lowered their nutrition
  risk scores after receiving home-based medical
  nutrition therapy

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On the Horizon Changes in Health Care and Its
Delivery

• The future offers much that is positive for the
  profession of dietetics
• Yet to be achieved are the effective provision
  and allocation of resources, such as nutrition
  services as part of preventive care

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On the Horizon Changes in Health Care and Its
Delivery

• A coordinated strategy for health care, political
  will, and active collaboration of both health
  care professionals and consumers of health care
  services will be required to achieve this goal
• Health care reform for the U.S. is certain, but
  the exact nature of the reform will continue to
  evolve

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Ethics and the Nutrition Professional

• What Is Ethics?
• A philosophical discipline that attempts to
  determine what is morally good and bad, right and
  wrong
• Codes of Ethics
• The ADA published its first code of ethics in
  1942
• Most recent code became effective in 1999
• ADA code applies to all ADA members and
  credentialed practitioners

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Ethics and the Nutrition Professional

• Guiding Principles
• Autonomy - respecting the individuals rights of
  self-determination, independence, and privacy
• Beneficence - protecting clients from harm and
  maximizing possible benefits
• Non-maleficence - the obligation not to inflict
  harm intentionally
• Justice - striving for fairness in ones actions
  and equality in the allocation of resources

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Ethics and the Nutrition Professional

• Health Promotion and Ethics
• Ethical Decision Making