Leadership by Example Coordinating Government Roles in Improving Health Care Quality (2003) / Chapter Skim
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2 Overview of the Government Health Care Programs
2 Overview of the Government Health Care Programs
Pages 28-55
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From page 28... ...
It is imperative that the federal government exercise strong leadership in addressing serious shortcomings in the safety and quality of health care in the United States. RECOMMENDATION 1: The federal government should assume a strong leadership position in driving the health care sector to improve the safety and quality of health care services provided to the approximately 100 million beneficiaries of the six major government health care programs.
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Thus, patients and clinicians would surely benefit from greater consistency in quality enhancement requirements, measures, and processes across public and private insurance programs. Table 2-1 provides a capsule summary of the six government health care programs.
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(e.g., children, pregnant level and women, disabled) 19 Benefits Basic acute care coverage, Comprehensive for both acute Medicaid some preventive; high cost and chronic care plus equivaler sharing, no prescription drugs institutional long-term care for managed the elderly, disabled, and in state; s mentally retarded; nominal sharing cost sharing Structure Federal Federal/state Federal/` Leading diagnoses Hypertension, osteoporosis, Childbirth, asthma, Not Avai chronic obstructive pulmonary hypertension, diabetes, disease, asthma, diabetes, heart congenital neurological and disease, and stroke developmental disorders, mental health and substance abuse, tuberculosis, sexually transmitted diseases, and HIV/AIDS Expenditures (2001)
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The over 30 percent of the Medicare population that has a physical and/or cognitive impairment accounts for about 60 percent of expenditures (see Figure 2-1~. Medicare beneficiaries with three or more chronic conditions account for the bulk of program expenditures (see Figure 2-2~.
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have been home health, skilled nursing facilities, and hospice care, reflecting a shift in demand toward more chronic care. MEDICAID2 Medicaid serves about 42 million people who are poor and who require health care services to achieve healthy growth and development goals or meet special health care needs.
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5(57%) Number of Chronic Conditions FIGURE 2-2 Medicare beneficiaries with five or more chronic conditions account for two-thirds of Medicare spending.
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These conditions include asthma, diabetes, neurological disorders, high blood pressure, mental illness, substance abuse, and HIV/AIDS (Centers for Medicare and Medicaid Services, 2001c; Medical Expenditure Panel Survey, 1996; Westmoreland, 1999~. STATE CHILDREN'S HEALTH INSURANCE PROGRAMS Designed as a joint federal-state program, SCHIP was created in 1997 to provide health insurance to poor and near-poor children through age 18 without another source of insurance.
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. DOD TRICARE5 DOD TRICARE encompasses two health care programs operated by the Department of Defense.
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TRICARE also has regional contracts with privatesector health plans to provide active-duty personnel with certain services not available through MTFs and to serve other beneficiaries. Non-activeduty beneficiaries may choose from among three program options: (1)
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Common inpatient diagnoses include diabetes, unintentional injuries, alcoholism, and substance abuse. BROAD TRENDS AFFECTING THE NEEDS AND EXPECTATIONS OF BENEFICIARIES In identifying ways to improve the quality enhancement processes of government health care programs, it is important to understand both the needs and expectations of today's beneficiaries and the trends likely to affect these needs and expectations in the future.
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health care resources is now devoted to the treatment of chronic disease (Anderson and Knickman, 2001~. This trend is strongly reflected in the government health care programs.
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These processes and the health care providers they monitor should be capable of assessing how well patients with chronic conditions are being managed across settings and time. This capability necessitates consolidation of all clinical and service use information for a patient across providers and sites, a most challenging task in a health care system that is highly decentralized and relies largely on paper medical records.
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For many chronic diseases, such as asthma, diabetes, obesity, heart disease, and arthritis, effective ongoing management involves changes in diet, increased exercise, stress reduction, smoking cessation, and other aspects of lifestyle (Fox and Gruman, 1999; Lorig et al., 1999; Von Korff et al., 1997~. Pressures to make the care system more respectful of and responsive to the needs, preferences, and values of individual patients also stem from the increasing ethnic and cultural diversity that characterizes much of the United States.
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Just as the quality enhancement processes of the government programs are being assessed in this report, these other aspects of program design must be evaluated in the future for alignment with the objectives of those processes. Benefits and Copayments Health insurance was established in the United States in the 1930s and 1940s as a way to help the average person cope with the high costs of hospital care (Stevens, 1989~.
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When one assesses the extent to which the government health care programs provide coverage for benefits important to persons with chronic conditions, the results are mixed (see Table 2-2~. The basic Medicare package, for example, generally does not cover outpatient prescription drugs or personal care, and coverage is very limited for preventive services, nursing home services, family counseling, and dietitian-nutritionist services.
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Its benefit package is very comprehensive, including complex therapies for chronic conditions and congenital neurological disorders, such as cerebral palsy and Down syndrome, although states vary substantially in the scope of such benefits. Both Medicaid and SCHIP programs cover outpatient prescription medications.
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The committee believes that each of the six government health care programs should review its benefit package and medical necessity criteria to identify enhancements in coverage or cost sharing that would facilitate the provision of more appropriate care to today's beneficiaries. Such analyses should be conducted under alternative financial scenarios, including budget neutrality and varying levels of growth in expenditures.
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Michigan, for example, has created a separately funded capitated option for children with special health care needs (Department of Health and Human Services, 2000~. Numerous options exist for risk-adjusting payments, but their application in government health care programs has been limited (Ellis et al., 1996; Hornbrook and Goodman, 1996; Newhouse et al., 1997; Starfield et al., 1991~.
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Services such as e-mail communications, telephone consultations, patient education classes, and care coordination are important for the ongoing management of chronic conditions, but they are not reimbursable events. Moreover, physicians who communicate with patients through email or telephone to emphasize patient education, self-management of chronic conditions, and to coordinate care may experience a reduction in overall revenues if these uncompensated services have the effect of reducing patient demand for or time available to devote to reimbursable faceto-face encounters.
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awards to care systems for performance on quality improvement projects (Bailit Health Purchasing, 2002a) · PacifiCare in California has developed a quality index that profiles providers on the basis of measures of clinical quality, patient safety, service quality, and efficiency.
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This initiative is being evaluated under an Agency for Healthcare Research and Quality contract. Program Design and Administration Benefits coverage and payment methods are among the most important design features of the six government health care programs reviewed in this report, but they are not the only ones that influence the likelihood of patients receiving high-quality care.
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In the absence of comparative quality information on providers, consumers apparently equate choice with quality. The design and financing of some government health care programs result in frequent changes in eligibility and delivery system options that disrupt patterns of care delivery.
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2002a. Ensuring Quality Health Plans: A Purchaser's Toolkit for Using Incentives.
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2000b. "State Children's Health Insurance Program (SCHIP)
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1999. " Patients as Effective Collaborators in Managing Chronic Conditions." Online.
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1996. Persons with chronic conditions.
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forthcoming. Medicare Expenditures Increase with the Number of Chronic Conditions; 1996 MEPS data.
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2001. Improving chronic illness care: translating evidence into action.
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