《JEFF资料库》-公共管理-美国医疗保险制度

LOGOUSHealthCareSystemJeffCheungLOGOTheDepartmentinchargeLOGODoctorsHospitalsLaboratories&MECPharmacies(Drugstore)PharmaceuticalCompanies(formularies)HomecareandotherspecialtycareLOGOFamilydoctors:one-to-onerelationshipSpecialists:specialtycareHospitals:inpatientandemergencycareDrugstores:drugprescriptionsPharmaceuticalcompanies:drugsundera“formulary”arrangementLOGOUninsured:seekemergencycareorMedicaidInsured:ChooseafamilydoctorFamilydoctorbecomesthe“caremanager”Familydoctormustmakereferral（转诊病人）tohospitalsMakeco-payasdefinedbypayers(officevisits,generic/brandnamedrug,out-of-pocketmaximums,etc.)LOGOGovernment:MedicareandstateMedicaidprogramsHealthinsuranceprograms/HMOPatientsLOGOPayclaimssubmittedbyproviders.Establish“reasonableandcustomary”feeschedule.Providecontractsbasedonpriceandquality.Managecarethroughpre-authorization,referrals（推荐）,casemanagement,andpreventivecare（预防性护理）.LOGOPeoplestayhealthyDiseasesarediagnosedearlyMinimizediseasecomplications（并发症）WhatbenefitshealthinsurancecompaniesLOGOPhysiciancontractingHospitalcontractingFormularyThisremovesall“extrabenefits”fromprovidersandallowhealthinsurancecompaniesto,intheory,passthebenefitstoconsumers.这排除了服务提供方的“额外收益”，而将此利益让渡给医疗保险公司，理论上说，是消费者受益。LOGO(A,B,andCinsurancecompanies)EachmarketmusthavemultipleProvidernetworks.CompeteonbothpriceandqualityLOGOFederalGovernmentisbyfarthelargestpayerthroughMedicareandMedicaid.Medicareisforpeople65yearsofageandolder.Medicarespendingwillmorethandoubleinthenextdecade,from$309billionin2004to$792billionin2015.Medicaidspendingisexpectedtoincreasefrom$293billionto$670billionduringthesameperiodLOGO•ClicktoaddText•ClicktoaddText•ClicktoaddTextHealthinsurancecompaniesareprivatebusinesswithP&LresponsibilitiesAdverseselectionPre-existingconditionInvestmentinhealthimprovementNationalHealthPlanisanentitlement（津贴）programnotsubjecttoaboveconcernsandshouldbelowercosttoimplement.NationalHealthPlanHealthInsuranceLOGO赞成方PeopleBusinessesGovernmentObstacles阻碍方CurrentstakeholderswhostandtoloseLOGOPeopleunder26canbecoveredbyparentsNopre-existingconditionforchildrenLifetime/annuallimitsremovedNopolicycancellationafterapersongetsillHealthplansmustofferelectronicrecordsNopre-existingconditions,healthstatus,norgenderCitizenspayfinefornotjoininghealthinsuranceEmployerspayfinefornotofferinghealthinsurance2010-20112013-2014LOGOOnMarch23,2010,PresidentObamasignedtheAffordableCareActintolaw,puttinginplacecomprehensivereformsthatimproveaccesstoaffordablehealthcoverageforeveryoneandprotectconsumersfromabusiveinsurancecompanypractices.LOGO