Bioengineering and World HealthLecture FiveUnit TwoEvery nation, whether it has many healthcare resources or only a few, must make decisions about how to use those resources to best serve its population. What is the difference in life expectancy between the America with the longest life expectancy and the America with the shortest life expectancy?Overview of Lecture 5 Health Systems What is a health system? Goals of a health system Functions of a health system Types of health systems Performance of Health Systems Examples of health systems How have health care costs changed over time? Health Care Reform in the US Eight AmericasHow Many $ to Gain a Year of Life? Need a way to quantify health benefits How much bang do you get for your buck? Ratio Numerator = Cost Denominator = Health Benefit Several examples $$/year of life gained $$/quality adjusted year of life gained (QALY) $$/disability free year of life gained (DALY) Can we use this to make decisions about what we pay for?League TableTherapy Cost per QALYMotorcycle helmets, Seat belts, Immunizations Cost-savingAnti-depressants for people with major depression $1,000Hypertension treatment in older men and women $1,000-$3,000Pap smear screening every 4 years (vs none) $16,000Driver’s side air bag (vs none) $27,000Chemo in 75 yo women with breast CA (vs none) $58,000Dialysis in seriously ill patients hospitalized with renal failure (vs none)$140,000Screening and treatment for HIV in low risk populations$1,500,000Centers for Medicare & Medicaid ServicesTable 1.4Sources of Health Insurance Coverage for the Under 65 Population, 1980-2000Notes: ESI - Employer Sponsored Insurance. Any Private includes ESI and individually purchased insurance. Any government includes Medicare for the disabled population.Source: Tabulations of the March Current Population Survey files by Actuarial Research Corporation, incorporating their historical adjustments.Over the last two decades, private coverage has declined, public coverage has stayed about the same, and the uninsured have grown.74%83%8%15%10%01020304050607080901980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000ESIAny PrivateMedicaidAny GovernmentUninsured74%69%16%14%9%What Happens When You Don’t Have Health Insurance? United States If you meet certain income guidelines, you are eligible for Medicaid Texas: TANF (welfare) recipients, SSI recipients Eligibility rules and coverage vary by state State pays a portion of the costs, federal govt. matches the resthttp://www.coaccess.com/images/mcdCard.gifCenters for Medicare & Medicaid Services28.8% to 33.9%More than 41.3%34.0% to 41.3%Less than 28.8%Table 3.30Births Financed by Medicaid as a Percent of Total Births by State, 1998Note: CO, GA 1997 data; KY, NJ, VT 1996 data.Source: Maternal and Child Health (MCH) Update: States Have Expanded Eligibility and Increased Access to Health Care for Pregnant Women and Children, National Governors Association, February, 2001, Table 23, at http://www.nga.org.WAORIDMT NDWYNVCAUTAZNMKSNEMNMOWITXIAILINARLAALSCTNNCKYFLVAOHMIWVPANYAKMDMEVTNHMARICTDEDCHINo dataCOGAMSOKNJSDMedicaid pays for about 1 in 3 of the nation’s births.What Happens When Medicaid Doesn’t Cover a Service? Oregon – July, 1987 Oregon state constitution required a balanced state budget, surplus returned to taxpayers Voted to end Medicaid coverage of transplants Typically 10 transplants performed per year $100,000-$200,000 per transplant $1.1 M cost to state (federal govt. pays the rest) Voted to fund Medicaid coverage of prenatal care Would save 25 infants who die from poor prenatal careA Tale of Two Children Oregon – August, 1987 Coby Howard 7 year old boy Developed leukemia Required a bone marrow transplant Was denied coverage Mom appealed to legislature, denied coverage Mom began media campaign to raise $$ Raised $70k ($30k short of goal) Coby died in December, 1987 Coby was “forced to spend the last days of his life acting cute” before the cameras Ira Zarov, attorney for patient in similar circumstancesA Tale of Two Children Oregon, 1987 David Holliday 2 year old boy Developed leukemia Moved to Washington state, lived in car Washington state Medicaid covered transplants No minimum residency requirementHealth Systems Face Difficult Choices Primary goal of a health system: Provide and manage resources to improve the health of the population Secondary goal of a health system: Ensure that good health is achieved in a fair manner Protect citizens against unpredictable and high financial costs of illness In many of the world’s poorest countries, people pay for care out of their own pockets, often when they can least afford it Illness is frequently a causeof poverty Prepayment, through health insurance, leads to greater fairnessHealth Systems Reflects historical trends in: Economic development Political ideology Provide four important functions: 1. Generate human resources, physical infrastructure & knowledge base to provide health care2. Provide health care services Primary clinics, hospitals, and tertiary care centers Operated by combination of government agencies and private providers 3. Raise & pool economic resources to pay for healthcare Sources include: taxes, mandatory social insurance, voluntary private insurance, charity, personal household income and foreign aid4. Provide stewardship for the healthcare system, setting and enforcing rules which patients, providers and payers must follow Ultimate responsibility for stewardship lies with the governmentActivityCreate Your Own Health SystemTypes of Health Systems Economic Classification Political Classification: Entrepreneurial Strongly influenced by market forces, some government intervention Welfare-oriented Government mandates health insurance for all workers, often through intermediary private insurance agencies Comprehensive Provide complete coverage to 100% of population almost completely through tax revenues Socialist Health services are operated by the government, and theoretically, are free to everyoneTypes of Health SystemsEntrepreneurial Welfare OrientedComprehensive SocialistHigh Income DevelopedUnited States Canada GermanyJapanAustraliaUnited KingdomSpainGreeceSoviet
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