mental health conditions (ch8)

HCA 3306, Community Health 1

Course Learning Outcomes for Unit VIII Upon completion of this unit, students should be able to:

2. Recognize effective principles of health programming for community health on a global scale. 2.1 Identify the types of programs available for global health issues. 2.2 Indicate the funding sources associated with health programs.

5. Evaluate the current treatment of mental disorders.

5.1 Describe the current treatment of mental disorders. 5.2 Discuss funding, political, and policy issues regarding mental disorders.

Course/Unit Learning Outcomes

Learning Activity

2.1 Unit Lesson Chapter 13 Unit VIII Scholarly Activity

2.2 Unit Lesson Chapter 13 Unit VII Scholarly Activity

5.1 Unit Lesson Chapter 14 Unit VIII Scholarly Activity

5.2 Unit Lesson Chapter 14 Unit VIII Scholarly Activity

Required Unit Resources Chapter 13: Organization, Financing, and Delivery of Health Services and Public Health Systems in the United States Chapter 14: Program Planning, Budgeting, Management, and Evaluation in Community Initiatives

Unit Lesson

Health Care Funding and Payment Models in the United States When we consider health care costs today, we must think in terms of charges, reimbursements, and out-of- pocket expenses. Charges are simply whatever price the health care provider decides to charge for a service. In the United States, there is no control whatsoever on charges for services. Typically, charges are much higher than reimbursement. Only uninsured patients are truly responsible for total charges. A typical hospital might charge two-to-three times the Medicare reimbursement rate for services, and some hospitals have charges much higher than that. Reimbursement is the actual payment received from a third-party payer for services rendered. For Medicare and Medicaid patients, the reimbursement rate is set by Centers for Medicare Services. Reimbursement rates are typically negotiated with commercial insurance plans and managed care organizations. Thinking in terms of a typical U.S. community hospital, reimbursement from Medicare might be in the range of 40–60% of charges. Medicaid reimbursement varies widely from state to state, but it might be in the range of 20–30% of charges. It is important to note that there are regional geographic differences in these payment rates and also

UNIT VIII STUDY GUIDE

Organization of Health Services and Public Health Systems

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differences based upon the provider’s status as rural or urban. Key point: hospitals and doctors can charge as much as they want for services, but that does not mean that any payer is willing to pay that amount. Who is stuck with the difference between charges and reimbursement is often the patient, and that is why medical bankruptcy is such a huge problem in our nation today. Out-of-pocket payments are hardest to determine because they vary so widely from plan to plan and patient to patient. They also vary significantly from one geographic region to another. We must always remember that this portion is what matters most to our patients. How much will this service cost out of the patient’s own pocket. The out-of-pocket cost often determines whether the service will in fact be accepted by the patient. Out-of-pocket payments come in the form of up-front co-pay amounts and co-insurance percentage payments. These are determined after the third-party payer has submitted reimbursement. Consider, for example, a client may have 80% coverage for a $300,000.00 organ transplant surgery, which will be life-saving, but if his or her out-of-pocket portion is still $60,000.00, he or she may not be able to receive the transplant. This is a tragic and real-world scenario today. It takes a focused team to get the patient through an organ transplant with family and friends who believe in the patient and are willing to commit to help.

Sources of Health Insurance Sources of health insurance in the United States have changed a little over recent decades. Some important statistics are listed below.

• For 2017, 8.8% of Americans (28.5 million persons) did not have health insurance coverage. That did not change from 2016, but it is significantly better than the peak uninsured rate of 15.5%, which occurred in 2010 (Berchick, et al.,2018). So, we do have progress on this key statistic! The Affordable Care Act is at least partially responsible for this reduction in uninsured Americans.

• In addition, 91.2% (296 million people) of Americans did have health insurance coverage during at least part of 2017, which is not different from the rate in 2016 but much better than the 2010 rate of 84% (Berchick et al., 2018). Again, there is evidence of some improvement in coverage. The problem has been the quality of the coverage obtained. Many of the newly insured Americans have very high deductibles and co-pays, so they are still out of pocket for most of their annual health care expenditures. However, they do have catastrophic coverage in the event of something very serious happing, perhaps a motor vehicle accident, heart attack, or stroke.

• In 2017, commercial health insurance (67.2% of Americans) was much more common than governmental forms of coverage (37.7%), and that is a key difference between the United States health system and most other national systems (Berchick et al., 2018). Around the world, national governments have a much larger role in insuring citizens than our government plays in the United States. The focus in America continues to be insuring the elderly and the poorest citizens, leaving working Americans to fend for themselves in terms of obtaining coverage. The health care exchanges, created by the Affordable Care Act, have opened the door for some Americans to obtain coverage, people who previously had no viable mechanism.

• Comparing 2016 and 2017, Medicare coverage increased by 0.6% to cover 17.2% of Americans (Berchick et al., 2018). This is predicable, and the trend will continue. The Baby Boomers born just after World War II are now aging together, many millions of them. As they reach Medicare age and having made their Medicare tax contributions over the course of a lifetime, they naturally want services. Many Americans put off the knee replacement or the back surgery or the cardiac workup until they know that the government will be paying for it, and it is hard to blame them. What that means for health care facilities across the nation is that they are already busier today and will be so much busier over the decades ahead. That is because the Baby Boomers now have Medicare coverage, and they are showing up at hospitals and clinics in large numbers!

• Military sponsored health care coverage went up from 4.6% to 4.8% between 2016 and 2017, and this percentage has actually been quite stable over recent decades (Berchick et al., 2018).

• Considering ethnic differences now, in 2017, whites had the lowest uninsured rate at 6.3%. The uninsured rates for African Americans and Asian Americans were 10.6% and 7.3% (Berchick et al., 2018). Hispanics had the highest uninsured rate at 16.1%. Hispanic Americans have had the lowest coverage rates for many years. A real opportunity to improve community health in America is to find

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better ways for all people to obtain health care coverage. That continues to be a real weak spot in our nation and a source of inequity and disparity in health!

Types of Coverage

Individual private insurance: These are individual insurance policies that involve the patient paying a premium directly to a health plan or commercial insurance company. Blue Cross/Blue Shield continues to be a major source of individual private insurance for Americans. The health care exchange, created by the Affordable Care Act, has expanded the choices available to Americans for individual private insurance. Employment-based private insurance: In the United States, employers often pay a portion of the premium, which purchases health insurance for their employees. Almost half of all Americans obtain health insurance via this mechanism. The federal government incentivizes employers and employees to do this in two ways. First, the cost of health insurance to the employer is considered a tax-deductible business expense. Second, the government does not treat the health fringe benefit as taxable income to the employee. It works for many companies and many Americans. By treating employer and employee health insurance plans in this way, the government is essentially subsidizing the program by roughly $200 billion each year. The problem over recent years is premium cost. As premiums have climbed year after year, some employers are simply finding it too expensive to offer coverage, or they may elect to offer very limited coverage with high deductibles and high co-pays. Meanwhile, employees have seen their portion of the premium skyrocket to the point that many employees have company-sponsored insurance, but they do not elect to take that coverage. It eats up too much of the paycheck. Government-sponsored insurance: Medicare Part A is a huge hospital insurance program for the elderly, which is funded through social security taxes. Upon turning 65 years of age, patients who have paid into social security for at least 10 years are enrolled in Medicare Part A. Also, patients who are under age 65 and totally and permanently disabled are enrolled, but only after 24 months of disability, and patients with end- stage renal disease requiring dialysis are also enrolled. Medicare Part B pays for physician services. It is financed by federal taxes and also by monthly premiums from beneficiaries. Medicare B is available to Medicare Part A beneficiaries who agree to pay a premium. For 2019, the Part B premium starts at $134.00 and goes up from there based upon patient income. Medicare Part D is a voluntary prescription coverage plan that was recently added to the Medicare program. The patient must have both Medicare A and Medicare B to enroll in Part D. There are premiums and deductibles, but for patients with expensive ongoing medication needs, the program is a great benefit. Medicaid is a federal government program, but it is administered by each state, and the states have come up with widely varying ways of administering it. The federal government pays 50% of total program costs in some states, and up to 75% of program costs in other states. Covered services include hospital, physician, laboratory, radiology, prenatal care, preventive care, and nursing home and home health care services. Enrollment in the Medicaid program is based upon low income status. The Affordable Care Act of 2010 (ACA) has certainly changed things in U.S. health care. Its goals were to reduce the number of uninsured Americans and to reduce overall health care costs. It certainly achieved that first goal, as many more Americans now have health care coverage. The jury is still out on the second goal of reducing overall health care costs. ACA raised the minimum income eligibility to 138% of the poverty level, opening the door for many more Americans to apply. It created health care exchanges to help families with income up to 400% of the poverty level to obtain coverage, and it expanded coverage to low income adults without children.

Conclusion Does health care coverage make a difference? Yes, it does. This has been thoroughly studied by the Henry J. Kaiser Family Foundation (2018), and it found that uninsured people get fewer regular medical visits and fewer preventive screening tests. They have higher rates of undiagnosed and uncontrolled hypertension, type 2 diabetes, and hypercholesterolemia. There is increased mortality and younger mortality in uninsured

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persons. The clinical outcomes during hospitalization are worse, including higher in-hospital mortality, likely because patients wait too long to seek care. Hopefully, this lesson has provided some insights into the ways in which Americans obtain health care coverage. Health insurance is important, very important, and we cannot truly say that we have quality health care in America until we have it for everyone.

References Berchick, E. R., Hood, E., & Barnett, J. C. (2018). Health insurance coverage in the United States: 2017

(Census Bureau Report No. P60-264). https://www.census.gov/content/dam/Census/library/publications/2018/demo/p60-264.pdf

Henry J. Kaiser Family Foundation. (2018). Key facts about the uninsured population.

http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population