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US Health Care Delivery Systems

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Robert McKinney

on 7 December 2015

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Transcript of US Health Care Delivery Systems

Thank You!
U.S. Health Care Delivery Systems
Per Capita Health Care Expenditures, 2009 (U.S. Purchasing Power Parity)
The United States spent 33% higher per capita on health care, than the next costliest country, Norway.
National Health Expenditures, 1960 to 2009
Quality of U.S. Healthcare
“What is perhaps most disturbing is the absence of real progress toward restructuring health care systems to address both
concerns, or toward applying advances in information technology to improve administrative and clinical processes.”

Committee on Quality Health Care in America, Institute of Medicine, 2001
Why is Public Health important?
According to the CDC, “…Overall, public health is concerned with protecting the health of entire populations. These populations can be as small as a local neighborhood, or as big as an entire country or region of the world.”
U.S. Healthcare Cost Comparison
Presented by: Group 1
US Health Care Delivery Systems, Public Health & PA Reimburstment
The total U.S. health care expenses costs over $2.5 trillion per year.

The costs, quality and access to health care are components that comprise the U.S. Health Care System.

With a gross net worth of $2.7 trillion dollars and an economic infrastructure larger than an entire country—Italy—it’s intricate structure faces difficulty at every level of health care.
What is Public Health?
According to the World Health Organization, health is the “…a state of complete physical, social, mental wellbeing, and not merely the absence of infirmity or disease.” We can see from this definition that health is seen holistically, with complete well-being being the goal.
The Center for Disease Control defines Public Health as “…the science of protecting and improving the health of families and communities through promotion of healthy lifestyles, research for disease and injury prevention and detection and control of infectious diseases.”
And the Institute of Medicine (IOM) defines public health (source The Future of the Public’s Health in the 21st Century, Institute of Medicine, 2002.) as, “…“the efforts, science, art, and approaches used by all sectors of society to assure, maintain, protect, promote, and improve the health of the people.”
Top 10 Public Health Achievements
1. Vaccination
2. Motor-vehicle safety
3. Safer workplaces
4. Control of infectious diseases
5. Decline in deaths from coronary heart disease and stroke
6. Safer and healthier foods
7. Healthier mothers and babies
8. Family planning
9. Fluoridation of drinking water
10. Recognition of tobacco use as a health hazard
The 3 Core Values of Public Health
1. Monitor environmental and health status to identify and solve community
environmental health problems

2. Diagnose and investigate environmental health problems and health hazards in the community

1. Inform, educate, and empower people about environmental health issues
2. Mobilize community partnerships and actions to identify and solve environmental health problems
3. Develop policies and plans that support individual and community environmental health efforts

Policy Development
1. Enforce laws and regulations that protect environmental health and ensure safety

2. Link people to needed environmental health services and assure the provision of environmental health services when otherwise unavailable

3. Assure a competent environmental health workforce

4. Evaluate effectiveness, accessibility, and quality of personal and population-based environmental health services

5. Research for new insights and innovative solutions to environmental health problems

Public Health in the US
Public health services exist across each level of government, from federal, state, and local government to various tribes and territories.

Public health in the USA is an essential part of our success as a prospering country. Public health in the USA provides such data as monitoring births and deaths, keeping accurate communicable disease reports, and monitoring teenage pregnancy rates in our country. Public health provides the framework in which we survive and thrive in a country.

According to the CDC, “Public health professionals try to prevent problems from happening or recurring through implementing educational programs, recommending policies, administering services and conducting research – in contrast to clinical professionals like doctors and nurses, who focus primarily on treating individuals after they become sick or injured. Public health also works to limit health disparities. A large part of public health is promoting healthcare equity, quality and accessibility.”

PA’s and Public Health
According to the CDC, “Public health professionals try to prevent problems from happening or recurring through implementing educational programs, recommending policies, administering services and conducting research – in contrast to clinical professionals like doctors and nurses, who focus primarily on treating individuals after they become sick or injured. Public health also works to limit health disparities. A large part of public health is promoting healthcare equity, quality and accessibility.”

Physician Assistants, as health care professionals, function to better and advance the health of the public by their practice. In specific, PA’s can serve as part of The Public Health Service Academy of Pas (PHSAPA), which, according to the AAPA, “…renders services to the medical profession and the public, while advocating for the unique needs of their constituent PAs. The PHSAPA is the AAPA constituent organization for active duty and retired PAs of the U.S. Public Health Service (USPHS), Coast Guard and many civil service PAs employed within the federal government.”

U.S. Healthcare
The U.S. Health care system includes hospitals, nursing homes, public and private physicians—both partnerships and organizations, specialty care facilities, non-profit organizations, pharmaceutical companies and insurance companies.
The U.S Healthcare system is the eighth largest economy and the second most complex health care system “in the world” and the issues its’ citizens face pales its economic status.
Patient Protection Act and Affordable Care Act are new milestones that put in place to ensure the efficiency and effectiveness of the U.S Health care system.

U.S. Healthcare is becoming more integrated and has devoted more resources to Mental Health Services and Public Health.
Overall, public health is concerned with the health of the public, of communities and families, groups and gatherings of all the people who make up our great and diverse world. This is important for both the survival of a country, and the thriving of all mankind in our world.
PA Reimbursement
Private Insurance Programs (HMO, PPO, fee-for-service, BlueCross/BlueShield, POS, EPO)
Health Maintenance Organization (HMO)
• Gives access to certain physcians and PA’s within network

• Restrictive within network

• Less coverage of medical expenses
• More affordable
Preferred Provider Organization (PPO)

• Allows patient more flexibility when picking physicians and PA’s

• Less restrictive

• More coverage of medical expenses

Point of Service Plan (POS)
Managaed care health insurance which combines chararcteristics of HMO and PPO to provide:

• Lower medical cost for limited services

• Required to choose PCP from POS network

Exclusive Provider Organization (EPO)

• Can only use physicians, PAs, and hospitals within the network

• Cannot go outside network for care

Nearly all private payers cover medical and surgical services done by PAs. Some payers will sepearately credential Pas while others require that the srvices done by the PA be billed under the name and NPI number of the Pas supervising physician.

Many private healthcare companies do not follow medicares coverage policy rules.Third party payers are able to establish their own rules and procedures, that’s why its important for a PA in practice to work with the physician to contact each company to verify the specific payment and coverage policies for PAs. PA coverage can change based on the patients insurance plan, the specific type of service being provided and the state in which the service was delivered.

The public health system is a network of organizations that coordinates efforts to protect, promote, and improve the health of the population as a whole. While governmental public health agencies such as, federal, state and local play an imperative role in the planning and delivery of public health services, many other organizations comprise the public health system, including health care providers and there corresponding associations.
An Overview of Public Health
Physician Assistants in Public Health Agencies
The Public Health Service Academy of Physician Assistants (PHASPA) is a constituent chapter of the American Academy of Physician Assistants (AAPA). The PHSAPA is the national organization for active duty and retired Physician Assistant officers of the United States Public Health Service and the United States Coast Guard. Their goals consist of public health promotion, disease prevention and advancing public health science.
Worker's Compensation for PA Reimbursement
Defining Worker's Compensation
- A program that provides insurance coverage for liabilities imposed for certain employers to pay benefits and care for employees injured on the job

- Provides some benefit payments to dependents of employees killed in the course of, or arising out of, their employment.

- Also known as industrial insurance
How Worker's Compensation Works
- Managed on a state-by-state basis
(note: The state may be the insurance entity or private insurers may handle that function.)

- Individual states determine and regulate the various provisions of workers' compensation programs

i.e. which practitioners may provide medical treatment, assess a worker's medical condition and certify a return-to-work status.
Coverage of PA services
- Determine a PA's covered services and may require additional supervision requirements

- May not authorize PAs to perform services outside their state law scope of practice.

(Note:Either the state, if acting as the insurance entity, or the private insurer determines the reimbursement for PAs services)
For more Information
- AAPA Reimbursement Department

"The Essential Guide to PA Reimbursement" is a one-stop resource for user-friendly explanations of PA reimbursement and coverage policies for PAs, physicians, billers and coders, hospital administrators and others. Found in AAPA's web store.

(Note: offers members detailed information about conditions of participation, services covered, reimbursement rates and supervision requirements. )
PA Reimbursment
Medical Services Delivered by Physician Assistants are covered by:
• Medicare

• Medicaid

• Tricare

• Other Private Payers

Medicare Basics

Medicare Part A
Hospital Insurance (inpatient, hospice care, home health care)

Medicare Part B
Medical Insurance (doctor’s visits, outpatient, preventive care, medical supplies)

Medicare Part C
Medicare Advantage Plans (private company that contracts with Medicare to provide both Part A and Part B)

Medicare Part D
Prescription Drug Coverage

Medicare & Medicaid
• 1977: First coverage was authorized by the Rural Health Clinic Services Act

• 1997: Balanced Budget Act authorized coverage to all types of practice settings at a uniform rate

• January 1, 1998: they pay the PA’s employer for the services provided by the PA at 85% of the physician’s fee schedule
“A fee schedule is a complete listing of fees used by Medicare to pay doctors or other providers/suppliers. This comprehensive listing of fee maximums is used to reimburse a physician and/or other providers on a fee-for-service basis.”
Services, both medical and surgical, are covered regardless of setting
Settings include:

Nursing facilities


Patient’s home

The Process:
Services provided by the PA are billed at the full physician rate

Medicare will see the PA’s National Provider Identification Number (NPI) and reduce the payment to 85% of the physician’s rate

Hospitals bill their clinical services under Medicare Part B for their PA’s

There is NO MEDICARE REQUIREMENT for the physician to have any contact with the patient or be on site for the service provided by the PA to be billed

Medicare however DOES REQUIRE that the physician maintain oversight on the patient’s ongoing care

*NPI is an identification number used by public and private third party payers
“Incident to” Billing
• Medicare “Incident to” Billing (Shared Visit Rules)

- Physician and Physician Assistant can combine on one claim the services they provided to the patient

- The claim is submitted under the Physician’s name and NPI with reimbursement of 100% but there is criteria that must be met

- ALL THE CRITERIA MUST BE MET to be able to submit the claim under the physician’s NPI and receive 100% reimbursement; if one criteria is not met, then it is billed under the PA and there is an 85% reimbursement

Medicaid Basics:
• Authorized by Title XIX of the Social Security Act

• Funded by federal and state governments

• Program the provides medical assistance to low-income families, individuals, children, the elderly, and the disabled

• Program began on January 1, 1966

• Today, covers more than 50 million people

Medicaid Coverage
PA services
• Different than Medicare because

Medicare requires PA services to be covered
Medicaid does not require the services to be covered; each state determines whether or not the services delivered by the PA are eligible to be covered

• All 50 states and D.C. cover PAs based on a fee for service or managed care plan (at a the same or slightly lower rate than physicians are covered)
Fee for service is when the health care provider is paid for each service (office visit, procedure, test, etc)
This is based more on quantity than quality
It is an incentive for practitioners to do more for the patient because the services are not bundled

Medicaid Coverage
PA Services

• Each state has their own rules on how they want the PA to bill for the service: either under the physicians name or under their own name with an identifier code

• Factors that affect coverage:
The patient’s insurance plan
Type of service being provided
State in which the service is being delivered

AAPA American Academy of Physician Assistants. 2015. Retrieved from https://www.aapa.org
Fee Schedules - General Information. 2015, May 9. Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FeeScheduleGenInfo/index.html?redirect=/FeeScheduleGeninfo/.
Hansen, S.H. Understanding Physician Assistant Reimbursement. UBM Medica Company. 2012, Feb. 17.
Integrating the Professions. 2015, June 1. Retrieved from http://cehs.tu.edu/paprogram/aboutus/integrating.html.
Medicaid.gov Keeping America Healthy. 2015. Retrieved from http://www.medicaid.gov/.
Medicare.gov The Official U.S. Government Site for Medicare. 2015. Retrieved from https://www.medicare.gov/.
Olmedo, USPHS, PA-C, B. (n,d). Public Health Service Academy of PAs. Retrieved November 9, 2015.

Public Health. 2015. Retrieved from http://www.who.int/trade/glossary/story076/en/.
Ten Great Public Health Achievements --- United States, 2001--2010. (2011, May 20). Retrieved November 9, 2015
The Future of the Public’s Health in the 21st Century, Institute of Medicine, 2002.
What is Public Health? (n.d.). Retrieved November 9, 2015, from http://www.cdcfoundation.org/content/what-public-health
Workers' Compensation. 2015, October 19. Retrieved from https://www.aapa.org/threecolumnlanding.aspx?id=1264
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