1. Health Care Policy in a NutshellHealth Care Policy in a NutshellHealth Care Policy in a NutshellHealth Care Policy in a Nutshell
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2. Welcome!Welcome!Welcome!Welcome!
Our one-hour session today will cover
Health Care Policy, including:
 Background and History of Health Policy
 Cost, Access, and Quality
 Proposed Solutions
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3. Background and History ofBackground and History of
Health PolicyHealth Policy
Background and History ofBackground and History of
Health PolicyHealth Policy 3

4. History of Health System and PolicyHistory of Health System and PolicyHistory of Health System and PolicyHistory of Health System and Policy
 Transformation of hospitals and the role of
physicians
 The role of government
• Presidents Teddy Roosevelt, Truman, Clinton
and Obama
• Medicare and Medicaid
• HMO Act of 1973 - Nixon
• 1997-SCHIP
• 2010 Health Care Reform
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5. History of Health System and PolicyHistory of Health System and PolicyHistory of Health System and PolicyHistory of Health System and Policy
Employers
 World War II
Health Insurers
 1847-First comprehensive group policy offered
by Massachusetts Health Insurance of Boston.
 1929 First Blue Cross Plan
 Managed Care – Mid-1990’s
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6. Who are the Stakeholders?Who are the Stakeholders?Who are the Stakeholders?Who are the Stakeholders?
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7. Who Pays What?Who Pays What?Who Pays What?Who Pays What?
Hospital Payment/Cost
Ratios
 Private Payers - 110% to
130%
 Medicare – 92% - 102%
 Medicaid – 80% - 95%
Private payers pay higher
reimbursement rates to
physicians
Source: Feldstein
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8. Health Care System DynamicsHealth Care System DynamicsHealth Care System DynamicsHealth Care System Dynamics
 DRG payment system
 Managed Care
• Provider Response
• Consumer Response
 Accountable Care Organizations, Shared
Savings and Patient Centered Medical Homes
• Provider Response
• Payer Response
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9. The Iron Triangle of Health Care PolicyThe Iron Triangle of Health Care PolicyThe Iron Triangle of Health Care PolicyThe Iron Triangle of Health Care Policy
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10. Health Care CostHealth Care CostHealth Care CostHealth Care Cost
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11. 2012 National2012 National
Health Care Expenditure DataHealth Care Expenditure Data
2012 National2012 National
Health Care Expenditure DataHealth Care Expenditure Data
Total Health Care Expenditures
 $2.823 Trillion
Hospital Care
 $873.1 Billion (31%)
Physician
 $542.9 Billion (19.2%)
Prescription Drugs
 $290.2 Billion (10.3%)
Source: CMS https://www.cms.gov/NationalHealthExpendData/downloads/tables.pdf
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12. Total Health Expenditure per Capita,Total Health Expenditure per Capita,
U.S. and Selected CountriesU.S. and Selected Countries
Total Health Expenditure per Capita,Total Health Expenditure per Capita,
U.S. and Selected CountriesU.S. and Selected Countries
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13. What are the cost drivers?What are the cost drivers?What are the cost drivers?What are the cost drivers?
 Medical Technology
 Payment structure
(fee for service)
 Fraud, waste and abuse
 Tax incentives
 Tort liability
 Lifestyle
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14. Health Care Costs and FloridaHealth Care Costs and FloridaHealth Care Costs and FloridaHealth Care Costs and Florida
• $132 billion in state health
expenditures in 2009
• $23 billion on Medicaid (including
federal share)
• Medicaid Reform
• Medicaid Expansion
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15. Medical Treatment vs. PreventionMedical Treatment vs. PreventionMedical Treatment vs. PreventionMedical Treatment vs. Prevention
Intervention Number of Lives Saved
per 1,000 Additional
Participants
Cost per Life Saved
NICU’s 2.8 $4,778
Prenatal Care 4.5 $39
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16. Health Care AccessHealth Care AccessHealth Care AccessHealth Care Access
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17. Two Major FactorsTwo Major FactorsTwo Major FactorsTwo Major Factors
 Ability to pay
 Labor supply
versus demand
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18. Ability to PayAbility to PayAbility to PayAbility to Pay
 Approximately 16.3% of Americans
are uninsured.
 Approximately 21% of Floridians are
uninsured.
 Education, jobs and health insurance
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19. Expanding Coverage Through the ACA?Expanding Coverage Through the ACA?Expanding Coverage Through the ACA?Expanding Coverage Through the ACA?
 Medicaid and
Subsidies
 Polarized political
climate
 State and federal
budget concerns
 Lingering legal issue
regarding federal
exchanges
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20. Supply of Primary Care PhysiciansSupply of Primary Care PhysiciansSupply of Primary Care PhysiciansSupply of Primary Care Physicians
 2007 survey showed that only 7% of medical
students planned to go into primary care.
 In Florida, 37% of non-federal physicians
practice primary care, compared to 39%
throughout the United States.
 15.1% of Floridians are underserved compared
to 11.4% nationwide.
Source: Kaiser Family Foundation
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21. Outlook for Physician DemandOutlook for Physician DemandOutlook for Physician DemandOutlook for Physician Demand
 Population growth
 Aging population
 Per capita income increasing, so
use of physicians are increasing
 More technology
 Increased use of lab tests and
imaging services
 Calls for more medical schools
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22. Outlook for Physician SupplyOutlook for Physician SupplyOutlook for Physician SupplyOutlook for Physician Supply
 Decreased work effort
expected
 Advanced Non-Physician
Practitioners
 Aging physicians: 61%
are 45 or older
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23. QUALITYQUALITYQUALITYQUALITY
Health Care QualityHealth Care QualityHealth Care QualityHealth Care Quality
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24. Definition of QualityDefinition of QualityDefinition of QualityDefinition of Quality
“The degree to which health services
for individuals and populations increase
the likelihood of desired health
outcomes and are consistent with
current professional knowledge.”
Source: IOM
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25. Quality:Quality: Who measures it and how?Who measures it and how?Quality:Quality: Who measures it and how?Who measures it and how?
 Service quality
 Clinical quality
• Process
• Outcomes
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26. OpportunitiesOpportunitiesOpportunitiesOpportunities
 Americans receive evidence based care 55% of
the time
 Medical errors cost the health care system
$17.1 billion nationally
 Death rates from cancer, heart disease and
stroke are higher among ethnic minorities in
Florida
 Defensive medicine
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27. Health Care ProposalsHealth Care ProposalsHealth Care ProposalsHealth Care Proposals
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28. ThemesThemesThemesThemes
 Cover the uninsured
 Improve quality
while increasing
efficiency within the
delivery system
 Wellness and
prevention
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29. High Level ACA IssuesHigh Level ACA IssuesHigh Level ACA IssuesHigh Level ACA Issues
 Expansion of coverage through
Medicaid and subsidies
 Health insurance market reforms and
exchanges
 Quality demonstration projects
 Public health initiatives
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30. ProposalsProposalsProposalsProposals
 Universal coverage (various
varieties)
 Aggressive outreach to
those that are currently
eligible for public programs
but are not enrolled
 Sustainable public
programs
 Bolster primary care
workforce
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31. ProposalsProposalsProposalsProposals
 Robust health
information network
 Comparative
effectiveness research
 Collaboration among
patients, providers
and payers
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32. ProposalsProposalsProposalsProposals
 Allow for creative and iteratively
innovative approaches to the
coordination and delivery of services that
focuses on the patient and increases
quality and efficiency
 Efforts to address health care disparities
and health literacy
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33. ProposalsProposalsProposalsProposals
 Maintaining healthy competition within
the delivery system
 Maximize efforts to reduce fraud, waste
and abuse in the health care system
• Tort reform
• Greater investment in law enforcement
• Use HIT to eliminate duplication and other waste
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34. ProposalsProposalsProposalsProposals
 Adequately fund safety net programs to
expand coverage to vulnerable
populations, that is fiscally sustainable
 Encourage worksite wellness programs
 Strategically craft public health
initiatives that will have the largest
impact
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35. Grow, Pay or Cut? Economic ConstraintsGrow, Pay or Cut? Economic ConstraintsGrow, Pay or Cut? Economic ConstraintsGrow, Pay or Cut? Economic Constraints
 Medicare
 Gross Domestic Product
 Federal Taxes
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36. Unauthorized EntitiesUnauthorized EntitiesUnauthorized EntitiesUnauthorized Entities
An entity that is required to be licensed or registered with the Florida
Office of Insurance Regulation but is operating without the proper
authorization is identified as an unauthorized insurer. All persons have
the responsibility of conducting reasonable research to ensure they are
not writing policies or placing business with an unauthorized insurer.
Any person who, directly or indirectly, aids or represents an
unauthorized insurer can lose their licenses or face other disciplinary
sanctions. Please see section 626.901, Florida Statutes, to read the
laws. Lack of careful screening can result in significant financial loss to
Florida consumers due to unpaid claims and/or theft of premiums.
Under Florida law, a person can be charged with a third-degree felony
and also held liable for any unpaid claims and refund of premiums
when representing an unauthorized insurer. It is the person’s
responsibility to give fair and accurate information regarding the
companies they represent.
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