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Chapter 62 - Health-Care Organization and Financing

from Section IV - Principles of Care for the Elderly

Published online by Cambridge University Press:  30 June 2022

By
Peter A. Hollmann
Edited by
Jan Busby-Whitehead ,
Samuel C. Durso ,
Christine Arenson ,
Rebecca Elon ,
Mary H. Palmer  and
William Reichel
Jan Busby-Whitehead
Affiliation:
University of North Carolina, Chapel Hill
Samuel C. Durso
Affiliation:
The Johns Hopkins University, Maryland
Christine Arenson
Affiliation:
Thomas Jefferson University, Philadelphia
Rebecca Elon
Affiliation:
The Johns Hopkins University School of Medicine
Mary H. Palmer
Affiliation:
University of North Carolina, Chapel Hill
William Reichel
Affiliation:
Georgetown University Medical Center
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Summary

By understanding health-care financing and organization, health-care professionals can provide more effective care and achieve financial success. This chapter covers basic insurance principles and key business operations concepts. There is a focus on Medicare (including Medicare Advantage) and Medicaid. Hospital and professional payment methods are explained. Steps that may help reduce health-care costs, such as better chronic care management, are presented. Whether the United States truly has a health-care system, the social spending crowd-out of health-care spending, and a brief international perspective are presented.

Keywords

financeinsuranceMedicareMedicaidcostspaymentUnited Statespopulation healthchronic illness
Type
Chapter
Information
Reichel's Care of the Elderly
Clinical Aspects of Aging
 , pp. 750 - 760
Publisher: Cambridge University Press
Print publication year: 2022

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References

https://news.gallup.com/poll/4708/healthcare-system.aspx. The public opinion organization, Gallup, provides data on public views of many dimensions of the health-care system and tracks them over decades.Google Scholar
www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective–2019. The Commonwealth Fund provides a succinct summary of international comparisons of health measures, health outcomes, service utilization, provider supply, and cost.Google Scholar
www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/Chartbook_Charts. Charts about the prevalence of conditions and functional limitations and costs.Google Scholar
www.healthsystemtracker.org/chart-collection/health-expenditures-vary-across-population/#item-start. Peterson-Kaiser Family Foundation (KFF) chart presentations based on analyses of the 2016 Medical Expenditure Panel Survey (MEPS) data showing costs by different populations (e.g., by age).Google Scholar
www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2018.05160. Health Affairs article on the 28% of Medicare beneficiaries who were persistently high cost over 3 years.Google Scholar
www.commonwealthfund.org/publications/issue-briefs/2016/aug/high-need-high-cost-patients-who-are-they-and-how-do-they-use. Using MEPS data from 2009–11, Commonwealth addresses costs of high-needs patients; that is, those with chronic conditions and functional limitations. Variations within high-cost populations are reviewed.Google Scholar
www.kff.org/medicare/issue-brief/an-overview-of-medicare. KFF overview of Medicare with useful links and succinct information.Google Scholar
www.kff.org/medicare/issue-brief/the-facts-on-medicare-spending-and-financing. KFF brief on Medicare spending. Succinct information supplementing the KFF Overview of Medicare.Google Scholar
www.urban.org/sites/default/files/publication/99748/rwjf451631_1.pdf. Urban Institute and Robert Woods Johnson (RWJ) Foundation regarding per-enrollee growth rates in federal programs.Google Scholar
www.cms.gov/files/document/2020-medicare-trustees-report.pdf. The 2020 Annual Trustees report on the Medicare funds that describes solvency projections.Google Scholar
www.medicare.gov/Pubs/pdf/11579-medicare-costs.pdf. Medicare’s public website information about benefits. This updates to the current year.Google Scholar
www.medicare.gov/your-medicare-costs/medicare-costs-at-a-glance. Medicare’s public website information about enrollee costs. This updates to the current year.Google Scholar
www.medpac.gov/docs/default-source/reports/mar19_medpac_ch12_sec.pdf. A chapter about hospice that is from MedPAC’s March 2019 Report to Congress on Medicare Payment Policy. MedPAC is an excellent source of data and policy recommendations. The Medicare Payment Advisory Commission is a nonpartisan legislative branch agency that provides the US Congress with analysis and policy advice.Google Scholar
www.kff.org/medicare/fact-sheet/medicare-advantage. KFF summary on Medicare Advantage (Part C).Google Scholar
www.kff.org/health-costs/press-release/beneficiaries-who-switch-to-medicare-advantage-have-lower-medicare-spending-and-use-fewer-services-in-prior-year-than-those-who-stay-in-traditional-medicare. KFF analysis of health-care consumption by patients that switch between traditional Medicare and Medicare Advantage plans.Google Scholar
www.kff.org/medicare/fact-sheet/an-overview-of-the-medicare-part-d-prescription-drug-benefit/#:~:text=Part%20D%20enrollees%20will%20also,2019%20to%20%244%2C020%20in%202020. KFF summary on Part D.Google Scholar
www.kff.org/medicare/issue-brief/how-much-do-medicare-beneficiaries-spend-out-of-pocket-on-health-care/#healthrelatedservices. KFF on out-of-pocket spending in Medicare.Google Scholar
www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet#:~:text=Medicaid%20spending%20grew%203.0%25%20to,34%20percent%20of%20total%20NHE. Centers for Medicare and Medicaid Services National Health Expenditures report, which has detailed information on health-care spending, not just federal costs.Google Scholar
www.kff.org/infographic/medicaids-role-in-nursing-home-care. A graphic about the role of Medicaid in paying for long-term care.Google Scholar
www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid-setting-the-facts-straight. KFF summary of some key facts about Medicaid. Since Medicaid varies by state, KFF also has state-by-state references.Google Scholar
www.aha.org/statistics/fast-facts-us-hospitals. American Hospital Association website on various hospital statistics.Google Scholar
www.mathematica.org/our-publications-and-findings/publications/evaluation-of-the-diffusion-and-impact-of-the-chronic-care-management-ccm-services-final-report. Mathematica’s report on the cost-effectiveness of chronic care management services.Google Scholar
www.healthaffairs.org/doi/full/10.1377/hlthaff.w4.184. One of the best articles about the relationship (or lack thereof) between physician spending and quality of care. Though from 2004, there is general agreement these relationships persist.Google Scholar
https://jamanetwork.com/journals/jama/fullarticle/2674671. An important article about why US costs differ from other developed nations.Google Scholar
https://jamanetwork.com/journals/jama/fullarticle/2752664. This article reviews waste in the US health-care system.Google Scholar
www.healthaffairs.org/doi/pdf/10.1377/hlthaff.28.1.75. Summary of the effectiveness of the Chronic Care Model.Google Scholar
www.improvingchroniccare.org/index.php?p=the_chronic_caremodel&s=2. The Chronic Care Model website.Google Scholar
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2687989. The cost-effectiveness of transitional care management is reviewed.Google Scholar

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