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Nursing fund
1. Issues Related to Health Care Financing
Overview of the size and growth of
the health care sector
The distribution of personal health
care services
Flow of Funds for Health Care
Nature of Financing Decisions
Judith R. Lave, Ph. D.
January 2004
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2. Share of National Health Expenditures,
By Type 2002
Total (Billions) $1,553
Total 100%
Personal Health Services 86.3
Prog. Admins + Net Cost of Health Insurance 6.8
Research & Construction 3.6
Public Health 3.3
Per Capita Expenditures $5,440
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3. Notes on Data
Summary Information: Jan/Feb Issues
of Health Affairs (K. Levit et al. Health
Spending Rebound Continues. Health
Affairs. 23(1), 2004.
Complete data:www.cms.gov: Search:
National Health Expenditures, Click:
Health Accounts. Click: Tables
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4. Annual Percent Change in National Health Spending
Selected Years
Current Dollars
1970-1980 12.9%
1980-1988 10.8
1988-1993 9.3
1993-1997 5.3
1997-2000 6.2
200-2001 8.5
2001-2002 9.3
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5. Many Definitions of Healthcare Costs
Healthcare Expenditures (p x q)
Prices of Individual Services
Premiums for Health Insurance
Out-of-Pocket Payments
% of GDP to Health Care (14.9%)
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6. National Health Expenditures as a Percent
of GDP
1970-2010
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
Accelerated growth
Managed care and
BBA impacts: “one-
time” effects on price
and volume levels
Moderate
Growth
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7. Distribution Expenditures on
Personal Health Care 2002
Prescription
drugs
12.1%10.4%
Nursing--
home
care
25.3%
Physician &
Clinical Services
36.3%
Hospitals
15.9%
Other
health
services
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8. Percentage Change in Expenditures
2000-20002
Category Percent Change
2000-2001 2001-2002
Overall 8.5% 9.3%
Hospital Care 7.5 9.5
Physician and Clinical Services 8.5 7.7
Nursing Home&Home Health 5.8 4.9
Prescription Drugs 15.9 15.3
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9. prem
ium
s,
general taxes,
payroll taxes,
state
lotteries
Households
Tax payers
The Financing of Health Care
out-of-pocket
payments
fee-for-service,
budgets,capitation
medical services
“claim
s”Financing Side Reimbursement Side
Third Parties
Government Agencies
Insurance Companies
(Health Plans)
prem
ium
s,
general taxes,
payroll taxes
Providers
(doctors, hospitals,
dentists, etc.)
Patients
Employers
Employees
10. Nonelderly Americans With Selected
Sources on Health
Insurance Coverage: 2002
Type of Coverage % of nonelderly
population *
Employment-Based Coverage
Individually Purchased
Public
Medicare
Medicaid
Tricare/CHAMPVA
No Health Insurance
64.2
6.7
15.9
2.3
11.9
2.8
17.3
Population: 250.8 million
* Does not add up to 100% because people can have
more than one source of health insurance
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11. Sources of Supplemental Coverage:
Among Non-Institutional Medicare
Beneficiaries: 1999
Other* 2%
Medicare
Only
13%
Employer-
Sponsored
33%
Medicaid
11%
Medigap
24%
Medicare
HMOs
17%
Total = 34.7 million non-institutional Medicare beneficiaries
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12. No Standard Health Plan
Health Insurance Policies Vary
With Respect to:
covered services
covered providers
administrative terms under which
services are accessed
methods for paying providers
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13. Importance of Insurance Coverage
Use of services is a function of price
(which depends on insurance structure
and coverage) (i.e., Claritin)
Decisions to cover or not cover certain
providers/technologies/services can
make or break an industry (i.e.,
physical therapy, mammograms,
obesity surgery)
Medicare is often pace-maker on ways
to pay providers
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14. Brief Discussion of Health
Care Financing Terms
Insurance policies vary considerably. They vary with
respect to which services will be covered, how much
cost sharing will be borne by the policy holder,
administration conditions under which
consumers/patients access care, what providers will
be covered, how much providers will be paid.
Private Health Insurance: Health insurance is
purchased in the market by groups (either through the
place of business or through professional associations)
or by individuals. The premium is the price paid for
the insurance policy. Under employer sponsored
group health insurance plans, the cost of the
premiums is paid in whole or in part by the employer.
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15. Definitions of Terms in the
Following Charts
Direct Patient Payments: This is the total
amount paid out of pocket by the patient or by
the patient’s family for a given service.
Private Third Parties: This is the total amount
paid for a given service on the behalf of the
consumer or services. This would include
payments made by blue cross, blue shield, a
health maintenance organization, Aetna, etc.
Public Federal: This is the total amount paid by
the federal government for health care. It
includes expenditures made under Medicare,
Medicaid, The Veteran’s Administration, etc.
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16. National Health Expenditures
By Source of Funds Selected Calendar Years
1970-2002
32.530.929.024.0Federal
45.944.042.637.8Public Funds
13.716.523.734.3Out of Pocket Payments
54.156.057.362.1Private Funds
35.433.627.721.2Private Health Insurance
5.05.95.96.6Other
13.413.113.613.7State & Local
100%100%100%100%Total
2002199319801970Source of Payment
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17. Percent of Personal Health Care
Expenditures
Paid Out of Pocket
1990 2002
Total 22.6% 15.8%
Hospital 4.4 3.0
Physician & clinical
services
20.5 10.1
Nursing Home care 40.4 25.1
Dental 48.3 44.0
Prescription Drugs 55.8* 30.0
*This is for 1992
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18. Source of Payment for Personal Healthcare:
Percent Distribution for Selected Services (2002)
Note: only selected sources enumerated
Medicaid
(Fed &
State)
Medi-
care
Out of
Pocket
Private
Insu-
rance
Total
PrivateTotal
Expendi-
tures
(billions)
Type of
Service
49.312.525.17.535.9100.0%103.2
Nursing
Home Care
17.60.230.047.877.7100.0%162.4
Prescription
Drugs (99)
5.4….44.049.593.6100.0%70.3
Dental
Services (99)
12.420.310.149.266.2100.0%339.5
Physician
Services
17.230.73.033.941.1100.0%486.2
Hospital
Care
17.419.315.835.855.8100.0%$1,340.2
Total Personal
Healthcare
GovernmentPrivate
Source of Expenditure (%)
19. What are some of the
problems that people
have with current
insurance?
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20. Employer Sponsored Health
Insurance
90% of Private Health Insurance Obtained
Through Employer
Employer Share of Premium Excluded
from Taxes
Employer Selects Plan
Who Bears the Cost?
Economists: The Employee in lower wages
Others: The Employer in lower profits
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22. New Wrinkle
Defined Contribution
1. Pay same amount towards all
plans offered by employer.
2. Pay employee fixed amount
divided between cash and a
catastrophic cap. Employee selects
a plan from a network of
providers.
3. Pay employee fixed amount to
purchase insurance privately.
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23. A Very Conservative Position
Decide how much you want to subsidize
health care—who do you want to help?
Get rid of the incentives that encourage
people to obtain their health insurance
through their employers.
Eliminate the tax subsidy of employer based
health insurance: treat all health insurance
equally—probably with a tax credit.
Let people use their own dollars to purchase
medical care/insurance—let them make their
own trade-offs. (could be defined
contribution)
Note: Similar to the A.M.A. position.
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24. Selected Policies By Third Parties
Control Over Prices
Government – Administered Prices
–Prospective Payment System
Hospitals – “DRG’s”
Nursing Home – “RUG’s”
Home Health Agencies –
“HHRG”
Outpatient Department –
- “APC”
Rehabilitation Facilities
– “FIM-
FRG”
DRG = Diagnoses Related Group
RUG = Resource Related Group
HHRG = Home Health Related
Group
APC = Ambulatory Patient
Classification
FIM-FRG = Functional
Independence Measure-
Function Related Group
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25. Development of Managed Care
Strongly Encouraged By Capitation
Selection of Physician/Providers who
Practice Cost-Effectiveness Care
Capitation of Primary Care (Gate-
Keeper and Other Providers)
Utilization Management
Care management
Preadmission screening
Concurrent review
Guidelines
Disease management
Introduction of Best Practices
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26. 35.0%
27.6%
13.8%
8.4%
9.20%
6.10%
7.7%
5.1%
10.3%
25.8%
49.9%
Percent Distribution of Medicare Enrollees an
Program Payments Under Medicare: CY 1998
29.3 Million Enrollees $168.2 Billion in Program
Payments
Percent of Persons Served Percent of Program Payments
$25,000 or More
$10,000-24,999
$5,000-9,999
$2,000-4,999
$25,000 or More
$10,000-24,999
$5,000-9,999
$2,000-4,999
$500-1,999
$1-499
AmountofProgramPayments
$500-1,999
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Source: Health Care Financing Administration, Office of the Actuary. Data are published in the Health Care Financing Review, and in
Health Affairs (usually the January/February issue) and they are also on the web at www.cms.gov.
Source: Center for Medicare & Medicaid Services, Office of the Actuary, National Health Statistical Group.
Note: BBA is Balanced Budget Act.
Source: Health Care Financing Administration, Office of the Actuary, data from the National Health Statistics Group.
Note: Other health services include dental services, other professions, durable medical equipment, over-the-counter medical products, home
health services, other personal health care, program administration, and the net cost of insurance, government public health activities, research,
and construction.
Personal Health Care: 1130.4
Source: Health Care Financing Administration, Office of the Actuary. Data are published in the Health Care Financing Review, and inHealth Affairs (usually the January/February issue) and they are also on the web at www.cms.gov.
Source: Employee Benefit Research Institute: Data based on March CPS Survey.
*Includes those receiving coverage from other public programs as well as those in non-risk HMOs.
SOURCE: Barents Group of KPMG Consulting’s analysis of the 1999 Medicare Current Beneficiary Survey.
Medicare: Medicare finances part of the care of the elderly (those eligible for Social Security), some of the permanently and totally disabled, and most people with end stage renal disease (kidney failure). It is a federal program. It is funded through payroll taxes (Part A), general tax revenue and premiums (Part B) and beneficiary cost sharing.
Medicaid: This is a federally sponsored and state administered program that pays for health care services for the indigent. Subject to broad federal guidelines, the states have considerable discretion in determining who is eligible for the program, what services and providers will be covered, and how much they will pay, to providers for rendering care.
Public State and Local: This includes the total amount spent by the state and local authorities for health care. It included the state share of Medicaid plus budget allocations to public hospitals to cover the cost of providing care to the poor not covered by Medicaid.
Source: Health Care Financing Administration, Office of the Actuary. Data are published in the Health Care Financing Review, and in
Health Affairs (usually the January/February issue) and they are also on the web at www.cms.gov.
Medicare Physician Fee Schedule
Private Plans
Negotiated prices
BIdding for business
Control Over Total Expenditures
Capitation
Medicaid HMOs
Medicare Risk Contracts
Private Sector HMOs
Expenditure Targets
Source: Health Care Financing Review: Medicare and Medicaid Statistical Supplemental, 2000, p. 32.
Note: There were 38.8 million Medicare Beneficiaries in 1998. Therefore, only 75% of them received any payment by Medicare.