US Healthcare SystemPPT课件

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--An Overview of the U.S.Health Care System[在U.S.Health保健系统的概述](PPT-128)

Personal Health Care Expenditures by Service, 1960-2003
13
Table 1.6
Annual Percent Change in Personal Health Care Expenditures for Medicare, Medicaid, and Total, 1971-2015
21
Table 1.14
Health Care Employment Growth Projections, 2000-2010
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Table 1.15
Average Annual Salaries of Selected Groups of Workers, 2005
23
Table 1.16
HMO Enrollment by Ownership Status, 1981-2004
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Table 1.7
Average Annual Growth in Medicare & Private Health Insurance Benefits Per Enrollee, Selected Periods
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Table 1.8
Concentration of Health Spending, 1987-2002
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Table 1.11
Sources of Payment for Nursing Home and Home Health Care, 2004
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Table 1.12
Number of People Employed in Health Care, 1990-2005
20
Table 1.13

美国百斯特医疗集团课件ppt1

建立和保持优秀文化
最有效的领导是那些能够预见并驾驭愿景所带来变革力量的人。 ——Beth Davis
建立和保持优秀文化
建立与组织选定的竞争优势（优质服务）相适应的优秀文化是百斯特管理层的当务之急。
百斯特刚刚完成了机构整合，每一个分支机构都有自己的文化，没有人可以从集团层面回答“我们是谁”这样一个简单的问题。
WOWs!》一书。这样做向员工传递了一个强有力的信息没有秘密，我们随时为你服务。
艾尔‧斯塔伯费尔德（Al 5绝地过反程击——服寻务找标竞准争和优绩势效标准 Stubblefield）被任命为集团的COO，采纳了顾问的建议，决心“建立一种全提供超级服务与集团选定的竞争优势相对应。
艾尔‧斯塔伯费尔德（Al Stubblefield）被任命为集团的COO，采纳了顾问的建议，决心“建立一种全社区乃至全国都没有体验过的服
百斯特集团的结论是一定要找到一个办法来让员工满意，然后他们自然会带来满意的病人。
此时，百斯特面临一个更加困难的问题如何让机构中都是满意的员工？
绝地反击——寻找竞争优势
艾尔认为，只有把医院打造成为一个员工愿意相处、愿意服务的医院，才能带来满意的员工。而这需要巨大的、认真的文化变革才能实现。
绝地反击——寻找竞争优势
竞争很痛苦，但也能带来丰硕的成果！
——Jerry Flint 艾尔‧斯塔伯费尔德在1999年成为百斯特集团的
CEO，并在此位置上一直服务到2012年。他在 2004年将百斯特文化变革的故事写成了《The Baptist Health Care Journey to Excellence: Creating a Culture That WOWs!》一书。《团队的五种机能障碍》的作者Patrick Lencioni 在序言中写道百斯特医疗不单单是一家杰出的机构，它是我们这个时代的榜样。它让我们看到一家机构的文化可以如此美丽，以及它如何使客户、员工、领导者和社区人员的生活都得到升华。

Health CarePPT课件

给某人施压有健康的饮食陷入贫困过着贫困的生活负担不起… 正如…的情况那样迎接挑战滞后落后包括几个方面应付各种需要一系列的重视…认真对待…
13.put extra pressure on sb. 14.keep a healthy diet 15.be forced into poverty 16.live in poverty 17.can’t afford to do sth. 18.as was the case with… 19.meet this challenge 20.be left behind 21.cover several aspects 22.meet all the needs 23.a series of… 24.be serious about sth
5.In how many cities is the health project being treated? A. 4. B. 5. C. 10. D. 14. 6. The text “A Helping Hand” is mainly about____ . A. millions of Chinese people in urban areas can’t afford proper health care B. the Chinese government is taking measures to prevent the spread of AIDS C. a new health care project is being explored and developed in China D. people must help each other if society is to develop and prosper

美国医疗保障制度-medical-care-systemPPT课件

Some employers no longer offer health coverage.
Others have increased the share paid by their employees
.
6
Getting insurance can be difficult for those who work only part time,
Public insurance is an insurance plan or policy that is subsidized by federal or state funds (Medicaid, Medicare).
.
10
The largest number of poor get medical help through
It also helps pay for some younger people who are disabled.
.
12
one must always exhaust private insurance payment options before applying for Medicare or Medicaid payment, and Medicaid will require someone dually eligible for Medicare and Medicaid to make application to Medicare first.
Others depend on private insurance. Companies guarantee to pay part or all of the costs of care. But the more the policy covers, the higher the price.

美国的健康保险与健康管理ppt课件

健康行为四改类变促策进健康行为改变的干预措施
略
干预技术
有效的证据
教育：改变知识、
确定教育的目的（认知、情感、
精神运动）(Bloom 1956)
态度和行为

阐明预期的结果和测量效益的标
准（Elder et al. 1994）
美国蓝十字和蓝盾
• 蓝十字和蓝盾起源于美国大萧条期间。通过管理计划提供医院服务和基本医疗服务。实质上是疾病管理，起因是为了保证病人来源。
• 后来目的成了更好地管理医疗卫生资源，不断地完善医疗服务质量，保证每个家庭享有高质量的可承受的医疗服务。
• 现在是全美最大的健康利益（福利）提供者，为九千两百多万人提供疾病和健康管理服务。
5 总目录章目录返回上一页下一页
美国凯撒健康计划和医疗集团（Kaiser Permanente）
• 起源１９３７年为水利工地，后来造船工厂和钢铁公司提供的职业医疗健康服务，通过按人头预收费提供全面医疗和健康服务和管理。强调健康和安全。
• 医疗卫生服务/健康管理模式：强调预防和健康维护，早期发现和早期治疗。
• 现在美国最大的健康维护组织(HMO)，为十七州的八
百万成员提供优质健康和疾病管理服务。
6 总目录章目录返回上一页下一页
１９７３年联邦健康维护组织法
• 为了控制政府ＭＥＤＩＣＡＲＥ的开支而设计的。
• “预付”改为“健康维护”。 • 政府提供创建基金和贷款，为州限制松
绑，２５个员工以上的雇主要允许员工选看病后报销的保险还是预付的保险。 • 健康维护组织（ＨＭＯ）大量出现
种类
顾问（包括心理学家和精神病治疗师）健康教育人员
营养学家
办公室医院诊所

医疗护理行业国际化英文通用PPT模板

Medical Care
Medical Care
第四节
Medical Care
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Medical Care
第二节
Medical Care
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Medical Care
40%
Medical Care
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dolor.
Medical Care
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美国医疗服务及医疗保险之概括(PPT 53张)

美国医疗服务及医疗保险之概括
---他山之石，可以攻玉？
2014年9月
报告内容
•美国医疗服务产业现状
•美国庞大医疗服务支出的趋势和因素
•美国商业医疗保险的发展及走向
•保险公司和医院－博弈中的伙伴
•奥巴马医改–难言成败
page 2
page 2
美国医疗服务产业架构
资金来源
资金管理服务机构
医疗服务单位
赔付机制
医院建筑，新设备，新技术人口老龄化，慢性疾病，肥胖药物过度医疗，浪费医疗，欺诈医疗, 诉讼人员开支，过多中间环节
page 14
商业医疗保险为医院补血
由于雇主提供的保险比重下降，在加州越来越多的人没有保险或者依靠政府保险或救助，医院不得不通过商业保险赔付来补偿这部分损失。
雇主提供的保险比重下降(1988 – 2012)
医疗保险诞生及存在之合理必要性
• 销售 • 大人群风险计算(大数据)，分担和预测 • 财务和合同规划,安排和实行 • 判断，谈判，签约医院和医生，有效降低单位服务价格 • 制定医疗和药品政策，监督管理签约医院医生药房的实际服务；控制压缩服务单位
• 至2020年美国将缺少 91,500名医生,至2025年该数字将超过130,600
Sources: AAMC 2012 Physician Specialty Data Book; AAMC 2013 State Physician Workforce Data Book page 6
美国医疗服务开支趋势全美医疗卫生支出占GDP的比例
卫生医疗专业人员
卫生医疗服务
个体
群体
page 3
美国医疗服务产业支出之分配
美国医疗卫生消费

(医学课件)美国医疗保健系统与管理保健最新PPT幻灯片

美国医疗保健系统与管理保健
US Health Care System and Managed Care
2019/6/17
1
医疗保险模式
国家医疗保险——英国社会医疗保险——德国商业医疗保险——美国储蓄医疗保险——新加坡
2019/6/17
2
商业医疗保险——美国
历史：1929年，“蓝十字”现代健康保险开端；内容：
2019/6/17
29
2019/6/17
30
卫生费用高昂的原因
人口老龄化；医疗服务价格高；全球最大的新药市场；医院“坏帐”；第三方付费。
2019/6/17
31
2019/6/17
30.8% 21.3% 10.2%
30.8% 21.2% 10.1%
812..96%%
1103..10%%
2019/6/17
23
Medicaid
由各州政府自行决定受益人资格、服务类型、项目等内容；
对象：低收入美国公民和合法移民（孕妇、儿童、18岁以下青年、65岁以上老年人、残疾人）；
筹资：州政府和联邦政府共同负担（逆向补助）；
补偿水平：很低的起付线、共付率（有些可免除）和封顶线限制，平均补偿率约80％；
（住院费、护理费、家庭护理费……）
Part B：Medical insurance；
（医生费用、检验费、救护车费用、血液费用……）
Part C：Combination of Part A and B；
Part D：Prescription Drug Coverage
对象：65岁以上美国公民，向国家缴税10年以上；终身残障者及其家属；ESRD患者；

U.S.health care system

The U.S. Health Care System: Best in the World, or Just theMost Expensive?"Of all the forms of inequality, injustice in health care is the most shocking and inhumane."— Martin Luther King, Jr.IntroductionFor many years, politicians and insurance companies could blithely proclaim that the U.S. had the best health care system in the world, but as its major shortcomings become more visible, Americans are findingit harder to accept this assertion. The 42.6 million people in the U.S. currently without health insurance are acutely aware that our health care system is not working for everyone, and there is growing recognition that the major problems of rising costs and lack of access constitute a real crisis. However, the search for solutions has not been easy or clear cut. Policymakers often attempt to address the symptoms of our health care crisis through short-term, patchwork solutions, under the pressure of time and the constraints of political decision-making, rather than analyzing the system itself as a whole. One important step in searching for effective longer-term solutions is to ask a deceptively simple two-fold question: how can we know whether a health care system is both "good" – that is, how well it does its job – and fair, in terms of financing health costs? If we can then analyze how well our health system performs, in comparison to other countries in the world, we will have a basis from which to explore possible alternatives.Characteristics of a Good and Fair Health Care SystemA number of recent studies have compared the health systems of various countries. Using information and concepts from these studies, it is possible to evaluate the health care system of the U.S. and other countries, with respect to such fundamental issues as cost, access to health care, and how well the health system succeeds in producing good health outcomes in a population.The World Health Organization (WHO) released a groundbreaking report in 2000, with data on the health systems of 191 member countries.1 In this analysis, WHO developed three primary goals for what a good health system should do: 1) good health: "making the health status of the entire population as good as possible" across the whole life cycle, 2) responsiveness: responding to people’s expectations of respectful treatment and client orientation by health care providers, and 3) fairness in financing: ensuring financial protection for everyone, with costs distributed according to one’s ability to pay. The WHO study also distinguished between the overall "goodness" of health care systems ("the best attainable average level") and fairness ("the smallest feasible differences among individuals and groups"). A health system which is both good and fair would thus ideally have:1 World Health Organization, The World Health Report 2000 – Health Systems: Improving Performance(Geneva: WHO, 2000).2Ibid., p. 27-35. Data from this study are also analyzed in Gerard Anderson and Peter Sotir Hussey, "Comparing Health System Performance in OECD Countries". Health Affairs; Vol. 20: No. 3 (May/June 2001); pp. 219-232.1) overall good health (e.g., low infant mortality rates and high disability-adjusted life expectancy);2) a fair distribution of good health (e.g., low infant mortality and long life expectancy evenly distributed across population groups);3) a high level of overall responsiveness;4) a fair distribution of responsiveness across population groups; and5) a fair distribution of financing health care (whether the burden of health costs is fairly distributed, based on ability to pay, so that everyone is equally protected from the financial risks of illness).3 Other major sources of international health system data include the OECD (Organization for Economic Cooperation and Development) data on its 29 member countries,4 the U.S. Census Bureau, and other international studies, including two studies comparing patient satisfaction in various countries.5 By using these health system data, we can compare the U.S. with a number of other roughly comparable, high-income OECD countries (e.g., relatively developed or industrialized).Here are some basic facts that stand out in doing such international comparisons:1) COST: The United States has by far the most expensive health care system in the world, based on health expenditures per capita (per person), and on total expenditures as a percentage of gross domestic product (GDP). As shown in Figure One and Table One, the United States spent $4,178 per capita on health care in 1998, more than twice the OECD median of $1,783, and far more than its closest competitor, Switzerland ($2,794).6 U.S. health spending as a percentage of GDP, 13.6 percent in 1998, also outdistanced the next most expensive health systems, in Germany (10.6 percent) and Switzerland (10.4 percent).The reasons for the especially high cost of health care in the U.S. can be attributed to a number of factors, ranging from the rising costs of medical technology and prescription drugs to the high administrative costs resulting from the complex multiple payer system in the U.S. For example, it has been estimated that between 19.3 and 24.1 percent of the total dollars spent on health care in the U.S. is spent simply on administrative costs.7 The growing shift from non-profit to for-profit health care providers, such as the growth of for-profit hospital chains, has also contributed to the increased costs of health care. By 1994, research showed that administrative costs among for-profit hospitals had increased to 34.0 percent, compared to 24.5 percent for private non-profit hospitals, and 22.9 percent for public hospitals.83 WHO (i bid.), p. 35.4 OECD, OECD Health Data 2000: A Comparative Analysis of Twenty-nine Countries (Paris: OECD, 2000).5 These studies, including Eurobarometer 49 (1998) and the Harvard School of Public Health, are described in: Robert J. Blendon, Minah Kim, and John M. Benson; "The Public Versus The World Health Organization onHealth System Performance"; Health Affairs; Vol. 20: No. 3; (May/June 2001); pp. 10-20.6 The data in Figure One replicate OECD cost data in Table One (source: OECD; Anderson and Hussey, ibid.)7 Steffie Woolhandler, M.D., M.P.H. and David U. Himmelstein, M.D., "The Deteriorating Administrative Efficiency of the U.S. Health Care System"; New England Journal of Medicine 324:1253-1258 (May 2), 1991. In contrast, administrative costs in Canada are from 8.4 to 11.1 percent of health care spending. The high level of administrative costs in the U.S. are due in large part to the additional personnel needed for billing and processing of private insurance, as well as advertising, market analysis, and tracking patients. (David Hackney and Debra Rogan, "A Single Payer Health Care System for the United States", American Medical Student Association, July 1, 2001).(/hp/sp.cfm)8 Steffie Woolhandler, M.D, M.P.H.. and David U. Himmelstein, M.D.; "Costs of Care and Administration at For-Profit and Other Hospitals in the United States"; New England Journal of Medicine 336:769-774 (March 13), 1997.In another stunning example demonstrating how for-profit health care contributes to high costs, Physicians for a National Health Plan reports: "When U.S. Healthcare merged with Aetna in 1996, the $967 million received by CEO Leonard Abramson could have provided health insurance to every uninsured child in the state of Massachusetts until they reached puberty." (Hackney and Rogan, ibid., citing Physicians for a National Health Plan, 1996).In addition, the high proportion of people who are uninsured in the U.S. (15.5 percent in 1999)9 contributes to expensive health care because conditions that could be either prevented or treated inexpensively in the early stages often develop into health crises. Treatment of crisis conditions later on is much more expensive, such as emergency room treatment, or intensive care when an untreated illness progresses to a more serious stage10. Finally, the aging of the population in the U.S. is also contributing to mounting increases in the cost of health care.FIGURE ONE:Health Spending Per Capita in Selected High-Income OECD Countries(in U.S. Dollars), 1998Given that we spend so much more of our societal resources on health care, what kind of return is the nation’s population receiving? This can be addressed by looking at some measures of health outcomes.2) ACCESS to health care: The U.S. is "the only country in the developed world, except for South Africa, that does not provide health care for all of its citizens."11 Instead, we have a confusing hodge-9 "Health Insurance Coverage", Current Population Reports, U.S. Census Bureau, September 2000.10American College of Physicians-American Society of Internal Medicine (ACP-ASIM), "Statement for the Record of the Ways and Means Health Subcommittee Hearing on the Nation’s Uninsured", April 4, 2001.(/hpp/ways_means.htm)11Stephen M. Ayres, M.D.; Health Care in the United States: The Facts and the Choices. Chicago and London: American Library Association: 1996, p. xii. South Africa, while providing universal coverage in principle, has not extended universal access in practice to all of its townships. (Ida Hellander, personal communication, 6/25/01,Physicians for a National Health Plan).podge of private insurance coverage based primarily on employment, along with public insurance coveragefor the elderly (Medicare), the military, veterans, and for the poor and disabled (Medicaid, which varies greatly in its implementation across states). Such a "non-system" creates serious gaps in coverage. And as insurance rates rise, more and more employers are forced to either drop their insurance benefits altogether,or to raise premiums and deductibles.According to the most recently available figures, 42.6 million people in America were uninsured in 1999, down slightly from 1997 and 1998 figures12. It is an embarrassment to many policy makers in theU.S. that we do not have universal coverage, but more seriously, it is a matter of life and death in many cases for people who do not have access to care.As the American College of Physicans-American Societyof Internal Medicine has pointed out, "people without health insurance tend to live sicker and die youngerthan people with health insurance".13 The lack of health insurance for a significant portion of Americansalso has other far-reaching consequences, as hospitals and other care providers are forced into cost shifting,at the expense of taxpayers and higher premiums for those with private insurance.14TABLE ONE:Health Care System Indicators and Rankingsin Selected High-Income OECD Countries, 1997-1999Rank)(WHO, Rank) (WHO, Rank) (See Blendon) (OECD) (OECD) (USCensus)(WHO) (WHO,Health Health Infant Disability- Fairness of Responsiveness Health System Percent Spending Per Spending as Mortality Adjusted Life Financial of Health Overall Satisfied withCapita in U.S. a Percent of Rate, Expectancy Contributions,System, Performance, Health System, COUNTRY Dollars, 1998 GDP, 1998 1998 & Rank, 97/ 991997 1997 1997 1998 & 2000United States 4,178 13.6 7.2 70.0 (24) 54-55 1 37 40 Australia 2,043 8.5 5.2 73.2 (2) 26-29 12-13 32 N.A.Canada 2,312 9.5 5.2 72.0 (12) 17-19 7-8 30 46Denmark 2,133 8.3 5.2 69.4 (28) 3-5 4 34 91Finland 1,502 6.9 3.9 70.5 (20) 8-11 19 31 81France 2,077 9.6 4.6 73.1 (3) 26-29 16-17 1 65 Germany 2,424 10.6 4.9 70.4 (22) 6-7 5 25 5822-23245-47208.4(6)Italy 1,7836.172.7(1) 8-11 6 10 N.A.74.57.6Japan 1,8224.0Luxembourg 2,215 5.9 5.1 71.1 (18) 2 3 16 67Norway 2,425 8.9 4.0 71.7 (15) 8-11 7-8 11 N.A.8.43.5 73.0 (4) 12-15 10 23 58Sweden 1,746Switzerland 2,794 10.4 4.7 72.5 (8) 38-40 2 20 N.A.U.K. 1,461 6.7 5.9 71.7 (14) 8-11 26-27 18 57OECD Median 1,783 8.212Ibid., "Health Insurance Coverage", U.S. Census, Sept. 2000. During 1999, 15.5 percent of the U.S. population was without health insurance coverage during the entire year. The three states with the highest percentage of uninsuredpeople were Texas, Arizona and New Mexico. Minnesota, Rhode Island and Hawaii had the lowest.13 The ACP-ASIM statement to the Ways and Means Subcommittee Hearing on the Nation’s Uninsured (ibid.)also points out that more than 80 percent of the uninsured are in working families.14A recent study by the Commonwealth Fund also found "sharp disparities in access to health care" among incomegroups in the U.S. In this survey, almost half (48 percent) of people with below-average incomes in the U.S. reportedthat it was "extremely, very, or somewhat difficult" to get medical care when they needed it; far higher than in theother four countries surveyed. (Cathy Schoen, Karen Davis, Catherine DesRoches, Karen Donelan, Robert Blendon,and Erin Stumpf; "Equity in Health Care Across Five Nations: Summary Findings from An International HealthPolicy Survey", May 2000. (/programs/international/schoen_5nat_ib_388.asp).3) HEALTH AND WELL-BEING: There are many different indicators of the overall health status and well-being of a country’s population, but among the most commonly used measures are infant mortality rates, and life expectancy, particularly disability-adjusted life expectancy ("the number of healthy years that can be expected on average in a given population").15 As of 1998, the infant mortality rate in the United States was 7.2 infant deaths per 1,000 live births (identical to the rates for 1996 and 1997). 16 Although this number is a historic low for the U.S., our infant mortality rate is nonetheless the highest among the OECD countries in Table One and Figure Two. In 1996, the U.S. ranked 26th among industrialized countries for infant mortality rates. 17These infant mortality figures for the U.S. are somewhat misleading, however, since they obscure the persisting wide disparities among racial groups, based in large part on economic differences. As the U.S. Department of Health and Human Services indicates, the infant mortality rate for black children (14.3 in 1998) is more than twice that of white children (6.0 deaths per 1,000 live births), and it is higher still in some areas of the country.18 For example, the 1999 infant mortality rate for black children in Alabama was 16.0 infant deaths before age one, among 1,000 live births.19 Many health policy analysts consider such figures a shocking indictment of living conditions for segments of the population in the richest country on earth.The WHO figures also show that the U.S. ranks very low (24th) on disability-adjusted life expectancy (DALE) among high-income OECD countries (see Table One); only Denmark ranked lower (28th). The U.S. also has a very unequal distribution of disability-adjusted life expectancy; particularly among males (in which some segments have a much longer disability-free life expectancy than others)20. This should not come as a surprise, however. When a sizable portion of the population lacks access to health care, particularly preventive care, one should expect that they would also be likely to experience more years of disability.2115 WHO; (/healthreport/pdf/dale.pdf). Disability Adjusted Life Expectancy (DALE) "summarizes the expected number of years to be lived in what might be termed the equivalent of ‘full health’."(http://www-nt.who.int/whosis/statistics/dale/dale.cfm?path=statistics,dale&language=english)16 U.S. Health and Human Services, "Preventing Infant Mortality", 2001 and 1997.17 The most recent complete comparative data analysis for infant mortality rates are from 1996, according to both the National Center for Health Statistics and the U.S. Department for Health and Human Services ("Preventing Infant Mortality", HHS Fact Sheet, U.S. Department of Health and Human Services, April 18, 2001.) The HHS fact sheet also points out that gains in medical research, public health and social services have produced a sharp decline in infant mortality rates in the U.S. since 1960. Figure Two replicates data in Table One (source: U.S. Census Bureau, ibid.)18Ibid.19 News Release, Alabama Department of Public Health, "Alabama’s infant mortality rate improves in 1999;" (/press/pr081600.htm).20Ibid., WHO; World Health Report 2000, ibid., p. 31.21 In addition, the U.S. has fairly high rates of H.I.V. infection, violence, coronary heart disease, and tobacco-related illnesses, compared to most industrialized countries. (WHO Press Release, "WHO Issues New HealthyLife Expectancy Rankings: Japan Number One in New ‘Healthy Life’ System"; June 4, 2000.)(http://www.who.int/inf-pr-2000/en/pr2000-life.html)FIGURE TWO:Infant Mortality Rates In Selected High-Income OECD Countries, 19984) RESPONSIVENESS: Based on WHO’s international comparisons, the U.S. was first among the 191 member countries in the category of responsiveness, the extent to which caregivers are responsive to client/patient expectations with regard to non-health areas such as being treated with dignity and respect, etc. However, this figure almost certainly covers over the existence of extreme disparities in responsiveness among different populations. In particular, it is obvious that the millions of people with either no insurance or else very limited access to health care via Medicaid, etc., have far greater problems finding responsive caregivers than those with an adequate degree of private health insurance coverage.5) FAIRNESS IN FINANCING: This measures the degree to which financial contributions to health systems are distributed fairly across the population. Table One shows that while OECD counties such as Luxembourg, Denmark and Germany have health systems which are very fair in financial contributions to the system, other countries such as the U.S. and Italy have very unfair systems of health financing. The U.S was the lowest (least fair) of all the OECD countries in Table One; tied for 54th and 55th place.An unfair system of financing has consequences for much of the population, but especially for those who are uninsured or underinsured, and for the poor. As the WHO report states, "the impact of failures in health systems is most severe on the poor everywhere, who are driven deeper into poverty by lack of financial protection against ill-health."2222 World Health Organization Press Release, "World Health Report 2000: World Health Organization Assesses the World’s Health Systems", June 21, 2000. The report adds, "The poor are treated with less respect, given less choice of service providers and offered lower-quality amenities. In trying to buy health from their own pockets, they pay and become poorer." (p. 2). (http://www.who.int/whr/2000/en/press_release.htm).6) ATTAINMENT AND PERFORMANCE: In addition to evaluating the world’s various health care systems using these criteria and providing other relevant health-related information, the WHO also ranked the world’s countries in terms of the overall attainment of their health systems (based on all five of the criteria, above), and the performance of their health systems – that is, how well a country’s health system is performing, compared to how well it could perform given its levels of resources. The results for overall attainment and performance were quite revealing: among the 191 countries listed, the U.S. health care system ranked 15th in the world for overall attainmen t (data not included in Table One), and 37th in the world for performance (see Table One).7) SATISFACTION WITH HEALTH CARE SYSTEM: One more interesting question is the extent to which ordinary people are satisfied with their country’s health care system. As shown in Table One, the two countries with the highest percentage of people who were either very satisfied or fairly satisfied with their country’s health care system overall were Denmark (91 percent!) and Finland (81 percent). Italy was the lowest among the European Union countries surveyed in the "Eurobarometer" study, at 20 percent. The U.S. was comparatively low also, with only 40 percent of people who were satisfied with their health care system. Even the United Kingdom, which has had persisting problems with its national health service in recent years,23 had almost 60 percent of its people saying they were either very satisfied or fairly satisfied.Implications and DiscussionThis paper has briefly described some of the most critical problems affecting the health care system in the U.S., such as access to health care, high costs, fairness, and effectiveness in bringing about good health in its population. There are many other major issues which also contribute to our mounting health care crisis, such as declining patient choices, the increased control in health care decisions by managed care companies as they seek to further limit access to care, the crisis in the nursing profession as nurses desert the profession in droves, and quality of care issues. It is becoming increasingly clear that these continuing dilemmas are unlikely to be solved without a thorough and creative overhaul of our present system.Despite the efforts of insurance companies and managed care companies to limit the range of political choices in health care reforms, there appears to be growing broad-based support in the U.S. for a single payer system which would greatly resolve some of the most serious problems of cost, access and fairness. Furthermore, recent studies have shown that a single payer plan would not only be economically feasible, but would be an enormous improvement over what we have. In 1991, for example, both the U.S. General Accounting Office (GAO) and the Congressional Budgeting Office (CBO) issued reports stating that a single payer system similar to that of Canada’s would more than pay for itself, due to reduced administrative costs, as well as having universal access to health care, especially preventive care.24 A single payer health insurance plan would not rule out a continuing role for private insurers, since it would probably provide only a basic level of coverage.25 In addition, recent surveys in the U.S. have documented the growing frustration with our health care system, and an interest in exploring a single payer plan for health insurance with universal coverage.26 Finally, recent efforts by Massachusetts health care policy 23 In 2000, the U.K. government unveiled "The NHS Plan", a new plan for reforming its National Health Service, in part to repair the damage from years of underfunding by previous governments. The British Council, "Health Insight August 2000". (/health/themes/insight/aug00/aug.htm)24 Physicians for a National Health Program, "How Much Does Single Payer National Health Care Cost?" PNHP Newsletter, October 1999. (/Health/HowMuchSPCost.html)25 In Canada, most of the population carries additional health insurance through employers for services notcovered by the provincially administered national insurance program.Karen S. Palmer, M.P.H., M.S.; "O Canada, Health Care Myths from the Great White North"; California Physicians Alliance, January 13, 1999.(/Health/O_Canada_KP.html)26Palmer, ibid. For example, 79 percent of Americans in a 1999 survey said that health care should be a right.analysts have shown that a single payer health care plan in Massachusetts would also be economically feasible27.One possible approach that has been advocated by some health care experts, for example, is to simply expand Medicare, an existing and highly successful public program which could be extended beyond the elderly to the entire population. Interestingly, Medicare costs for administration are currently less than two percent.28 This and other alternative models need to be explored and discussed, with the help of current and unbiased information. It is clearly imperative, therefore, that policymakers and lay people alike educate ourselves on the issues, and to exercise our collective imagination and creativity in meeting these challenges.We wish to acknowledge the helpful assistance of Ida Hellander, Physicans for a National Health Plan,and JoAnne Bailey, U.S. General Accounting Office.A Member of the University of Maine SystemPrepared as a public service by theBureau of Labor EducationUniversity of MaineOrono, MaineSummer, 200127 Massachusetts Medical Society House of Delegates Report 207, A-99 (B), cited in Physicians for a National Health Program, ibid., "How Much Does Single Payer National Health Care Cost?"28A Profile of Medicare: Chartbook 1998, U.S. Health Care Financing Administration; May 1998, p. 27.。

第七章美国医疗保健系统与管理保健最新教材

2019/5/18
13
医疗开支：最大的决定因素？
PID: no impact
(诱导需求)
Defensive medicine: 1%
（减少不确定性的防御性医疗）
Aging: 7%
（老龄化）
Insurance: 10%
Income: 5 ~ 25%
Technology: > 50%
主要健康问题
1980至今
慢性疾病（尤其是与工作场所、环境和遗传相关的心理、行为疾病，如艾滋病、心理疾病等）
医疗技术
医疗组织人们医疗参与程度
医学技术（器官移植、基因治疗、核磁共振等）成为医疗体系的主要驱动力，医疗支出上升
医疗服务机构组织形式变革与效率改进
民众医学知识迅速膨胀，然而面对医疗服务系统的复杂程度和昂贵的医疗费用感到越来越失望和无助
有人认识到疾病的经济损失以及需要对这种损失进行保险，所以
那时还没有真正意义上的医疗保险产品。
1850年，富兰克林健康保险公司（非致死性损伤保险）；
1860年，旅行者保险公司（与今天的健康险很相似）；
人们医疗参与民众开始得到一些医学知识和教育，更多
程度
依赖医院和医生完成护理
2019/5/18
9
主要健康问题：特定病例的特殊治疗、诊断技术、外伤治疗技术
（肺炎病人的血清疗法，发现糖尿病病人的胰岛素疗法……）
医学教育与医学研究：
放射诊断技术……
2019/5/18
ቤተ መጻሕፍቲ ባይዱ
10
第三阶段
二战－1980
主要健康问题慢性疾病（心脏病、癌症和中风等）
疾病，如艾滋病、抑郁症、自

【医学PPT课件】Health care delivery system

21
Tertiary care
Pediatric surgery Positron emissions tomography (PET) Radiation oncology Services provided to a person with a high-risk
7
Evolution of health care delivery in the United States
1991 The Workgroup on Electronic Data Interchange (WEDI) was created to reduce health care administrative costs through implementation of the electronic data interchange (EDI), which uses national standards to transmit data for reimbursement purposes.
16
Tertiary care services
Provided by specialized hospitals equipped with diagnostic and treatment facilities not generally available at hospitals other than primary teaching hospital or Level I, II, III or IV trauma centers.
Primary care Secondary care Tertiary care
13
Primary care services
Include preventive and acute care, are referred to as the point of first care, and are provided by a general practitioner or other health professional who has the first contact with a patient seeking medical treatment, including general dental, ophthalmic 眼科的, and pharmaceutical services.

US health care system 美国医疗保险体系介绍

Medicare Program - General InformationMedicare is a health insurance program for:∙people age 65 or older,∙people under age 65 with certain disabilities, and∙people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis ora kidney transplant).Medicare has:Part A Hospital Insurance - Most people don't pay a premium for Part A because they or a spouse already paid for it through their payroll taxes while working. Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Beneficiaries must meet certain conditions to get these benefits.Part B Medical Insurance - Most people pay a monthly premium for Part B. Medicare Part B (Medical Insurance) helps cover doctors' services and outpatient care. It also covers some other medical services that Part A doesn't cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.Prescription Drug Coverage - Most people will pay a monthly premium for this coverage. Starting January 1, 2006, new Medicare prescription drug coverage will be available to everyone with Medicare. Everyone with Medicare can get this coverage that may help lower prescription drug costs and help protect against higher costs in the future. Medicare Prescription Drug Coverage is insurance. Private companies provide the coverage. Beneficiaries choose the drug plan and pay a monthly premium. Like other insurance, if a beneficiary decides not to enroll in a drug plan when they are first eligible, they may pay a penalty if they choose to join later.Medicare Part AMedicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Certain conditions must be met to get these benefits.Cost: Most people don’t have to pay a monthly payment, called a premium, for Part A. This is because they or a spouse paid Medicare taxes while working. If a beneficiary doesn't get premium-free Part A, they may be able to buy it if they (or their spouse) aren’t entitled to Social Security, because they didn’t work or didn’t pay enough Medicare taxes while working, are age 65 or older, or are disabled but no longer get free Part A because they returned to work.Medicare Part BMedicare Part B (Medical Insurance) helps cover doctors' services and outpatient care. It also covers some other medical services that Part A doesn't cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.Cost: The Medicare Part B premium each month ($99.90 per month in 2012). In some cases, this amount may be higher if the beneficiary didn't sign up for Part B when they first became eligible.Caution: If the beneficiary didn't take Part B when they were first eligible, the cost of Part B will go up 10% for each full 12-month period that they could have had Part B but didn't sign up for it, except in special cases. They will have to pay this penalty as long as they have Part B.They also pay a Part B deductible each year before Medicare starts to pay its share. The Part B deductible for 2012 is $140.00. The beneficiary may be able to get help from their state to pay this premium and deductible.Medicare deductible and premium rates may change every year in January.Medicare Advantage PlansA Medicare Advantage Plan is a type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and PartB benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you're enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren't paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.Health Maintenance Organization (HMO) PlanIn most HMO Plans, you can only go to doctors, other health care providers, or hospitals on the plan's list except in an emergency. You may also need to get a referral from your primary care doctor.Can you get your health care from any doctor, other health care provider, or hospital?In HMO Plans, you can't get your health care from any doctor, other health care provider, or hospital. You generally must get your care and services from doctors, other health care providers, or hospitals in the plan's network (except emergency care, out-of-area urgent care, or out-of-area dialysis). In some plans, you may be able to go out-of-network for certain services, usually for a higher cost. This is called an HMO with a point-of-service (POS) option.Are prescription drugs covered?In most cases, prescription drugs are covered in HMO Plans. Ask the plan. If you want Medicare prescription drug coverage (Part D), you must join an HMO Plan that offers prescription drug coverage.Do you need to choose a primary care doctor?In most cases, yes, you need to choose a primary care doctor in HMO Plans.Do you have to get a referral to see a specialist?In most cases you have to get a referral to see a specialist in HMO Plans. Certain services, like yearly screening mammograms, don't require a referral.What else do you need to know about this type of plan?∙If your doctor or other health care provider leaves the plan, your plan will notify you. You can choose another doctor in the plan.∙If you get health care outside the plan's network, you may have to pay the full cost.∙It's important that you follow the plan's rules, like getting prior approval for a certain service when needed.Preferred Provider Organization (PPO) PlansHow PPO Plans WorkA Medicare PPO Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurancecompany. In a PPO Plan, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan's network. You pay more if you use doctors, hospitals, and providers outside of the network.Can you get your health care from any doctor, other health care provider, or hospital?In most cases, you can get your health care from any doctor, other health care provider, or hospital in PPO Plans. PPO Plans have network doctors, other health care providers, and hospitals.Each plan gives you flexibility to go to doctors, specialists, or hospitals that aren't on the plan's list, but it will usually cost more.Are prescription drugs covered?In most cases, prescription drugs are covered in PPO Plans. Ask the plan. If you want Medicare drug coverage, you must join a PPO Plan that offers prescription drug coverage. Remember, if you join a PPO Plan that doesn't offer prescription drug coverage, you can't join a Medicare Prescription Drug Plan (Part D).Do you need to choose a primary care doctor?You don't need to choose a primary care doctor in PPO Plans.Do you have to get a referral to see a specialist?In most cases, you don't have to get a referral to see a specialist in PPO Plans. If you use plan specialists, your costs for covered services will usually be lower than if you use non-plan specialists.What else do you need to know about this type of plan?A PPO Plan isn't the same as Original Medicare or a Medicare Supplement Insurance (Medigap) policy.PPO Plans usually offer extra benefits than Original Medicare, but you may have to pay extra for these benefits.Medicare Special Needs Plans (SNP)How Medicare SNPs workMedicare SNPs are a type of Medicare Advantage Plan (like an HMO or PPO). Medicare SNPs limit membership to people with specific diseases or characteristics, and tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve.Can I get my health care from any doctor, other health care provider, or hospital?Generally, you must get your care and services from doctors or hospitals in the Medicare SNP network (except emergency or urgent care, such as care you get for a sudden illness or injury that needs medical care right away, or if you have End-Stage Renal Disease (ESRD) and needout-of-area dialysis). Medicare SNPs typically have specialists in the diseases or conditions that affect their members.Are prescription drugs covered?All SNPs must provide Medicare prescription drug coverage.Do I need to choose a primary care doctor?In most cases, SNPs may require you to have a primary care doctor, or the plan may require you to have a care coordinator to help with your health care.Do I have to get a referral to see a specialist?In most cases, you have to get a referral to see a specialist in SNPs. Certain services, like yearly screening mammograms or an in-network pap test and pelvic exam (covered at least every other year), don't require a referral.What else do I need to know about this type of plan?A plan must limit membership to these groups: 1) people who live in certain institutions (like anursing home) or who require nursing care at home, or 2) people who are eligible for both Medicare and Medicaid, or 3) people who have specific chronic or disabling conditions (like diabetes,End-Stage Renal Disease (ESRD), HIV/AIDS, chronic heart failure, or dementia). Plans may further limit membership. You can join a SNP at any time.Plans should coordinate the services and providers you need to help you stay healthy and follow doctor’s or other health care provider’s orders.If you have Medicare and Medicaid, your plan should make sure that all of the plan doctors or other health care providers you use accept Medicaid.If you live in an institution, make sure that plan providers serve people where you live.∙HMO Point of Service (HMOPOS) Plans: An HMO Plan that may allow you to get some services out-of-network for a higher cost.∙Medical Savings Account (MSA) Plans: A plan that combines a high deductible health plan with a bank account. Medicare deposits money into the account (usually less than the deductible). You can use the money to pay for your health care services during the year.Part A costsYou usually don't pay a monthly premium for Medicare Part A (Hospital Insurance) coverage if you or your spouse paid Medicare taxes while working. This is sometimes called "premium-free Part A."How much does Part A cost?If you buy Part A, you'll pay up to $451 each month in 2012. In 2013, you'll pay up to $441 each month. But, most people get premium-free Part A. You can get premium-free Part A at 65 if:∙You already get retirement benefits from Social Security or the Railroad Retirement Board.∙You're eligible to get Social Security or Railroad benefits but haven't filed for them yet.∙You or your spouse had Medicare-covered government employment.If you're under 65, you can get premium-free Part A if:∙You got Social Security or Railroad Retirement Board disability benefits for 24 months.∙You have End-Stage Renal Disease (ESRD) and meet certain requirements.In most cases, if you choose to buy Part A, you must also have Medicare Part B (Medical Insurance) and pay monthly premiums for both.Some people automatically get Medicare Part A (Hospital Insurance).Part B costsYou pay a premium each month for Medicare Part B (Medical Insurance). Most people will pay the standard premium amount. However, if your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you may pay more.How much does Part B cost?Most people pay the Part B premium of $99.90 each month in 2012 ($104.90 in 2013).You pay $140 per year for your Part B deductible in 2012 ($147 in 2013).Some people automatically get Part B.If you don't sign up for Part B when you're first eligible, you may have to pay a late enrollment penalty.If your modified adjusted gross income as reported on your IRS tax return from 2 years ago (the most recent tax return information provided to Social Security by the IRS) is above a certain amount, you may pay more.Social Security will contact some people who have to pay more depending on their income. The amount you pay can change each year depending on your income. If you have to pay a higher amount for your Part B premium and you disagree (for example, if your income goes down), please contact Social Security.Costs for Medicare drug coverageYou'll make these payments throughout the year in a Medicare drug plan:∙Monthly premium∙Yearly deductible∙Copayments or coinsurance∙Costs in the coverage gap∙Costs if you get Extra Help∙Costs if you pay a late enrollment penaltyYour actual drug plan costs will vary depending on:∙The drugs you use∙The plan you choose∙Whether you go to a pharmacy in your plan's network∙Whether the drugs you use are on your plan's formulary∙Whether you get Extra Help paying your Medicare Part D costsIf you have limited income and resources, your state may help you pay for Part A and/or Part B.You may also qualify for Extra Help to pay for your Medicare prescription drug coverage.Costs for Medicare health plansWhat you pay in a Medicare health planYour out-of-pocket costs in a Medicare Advantage Plan (Part C) depend on:∙Whether the plan charges a monthly premium.∙Whether the plan pays any of your monthly Medicare Part B (Medical Insurance) premium.∙Whether the plan has a yearly deductible or any additional deductibles.∙How much you pay for each visit or service (copayment or coinsurance). For example, the plan may charge a copayment, like $10 or $20 every time you see a doctor. These amounts can be different than those under Original Medicare.∙The type of health care services you need and how often you get them.∙Whether you go to a doctor or supplier who accepts assignment (if you're in a PPO, PFFS, or MSA plan and you go out-of-network).∙Whether you follow the plan's rules, like using network providers.∙Whether you need extra benefits and if the plan charges for it.∙The plan's yearly limit on your out-of-pocket costs for all medical services.∙Whether you have Medicaid or get help from your state.NoteEach year, plans establish the amounts they charge for premiums, deductibles, and services. The plan (rather than Medicare) decides how much you pay for the covered services you get. What you pay the plan may change only once a year, on January 1.What does Medicare Part A cover?What is covered?Medicare covers services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) considered medically necessary to treat a disease or condition.If you're in a Medicare Advantage Plan or other Medicare plan, you may have different rules, but your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions.In general, Part A covers:∙Hospital care∙Skilled nursing facility care∙Nursing home care (as long as custodial care isn't the only care you need)∙Hospice∙Home health services2 ways to find out if Medicare covers what you need1. Talk to your doctor or other health care provider about why you need certain services orsupplies, and ask if Medicare will cover them. If you need something that's usually covered andyour provider thinks that Medicare won't cover it in your situation, you'll have to read and sign a notice saying that you may have to pay for the item, service, or supply.2. Find out if Medicare covers your item, service, or supply.Medicare coverage is based on 3 main factors1. Federal and state laws.2. National coverage decisions made by Medicare about whether something is covered.3. Local coverage decisions made by companies in each state that process claims for Medicare.These companies decide whether something is medically necessary and should be covered in their area.What does Medicare Part B cover?What's covered?Medicare covers services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) considered medically necessary to treat a disease or condition.If you're in a Medicare Advantage Plan or other Medicare plan, you may have different rules, but your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions.Part B covers 2 types of services∙Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.∙Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.You pay nothing for most preventive services if you get the services from a health care provider who accepts assignment.Part B covers things like:∙Clinical research∙Ambulance services∙Durable medical equipment∙Mental health∙Inpatient∙Outpatient∙Partial hospitalization∙Getting a second opinion before surgery∙Limited outpatient prescription drugs2 ways to find out if Medicare covers what you need∙Talk to your doctor or other health care provider about why you need certain services or supplies, and ask if Medicare will cover them. If you need something that's usually covered and yourprovider thinks that Medicare won't cover it in your situation, you'll have to read and sign a notice saying that you may have to pay for the item, service, or supply.∙Find out if Medicare covers your item, service, or supply.Medicare coverage is based on 3 main factors1. Federal and state laws.2. National coverage decisions made by Medicare about whether something is covered.3. Local coverage decisions made by companies in each state that process claims for Medicare.These companies decide whether something is medically necessary and should be covered in their area.What drug plans coverEach Medicare Prescription Drug Plan has its own list of covered drugs (called a formulary). Many Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost.A drug in a lower tier will generally cost you less than a drug in a higher tier. In some cases, if yourdrug is on a higher tier and your prescriber thinks you need that drug instead of a similar drug on a lower tier, you or your prescriber can ask your plan for an exception to get a lower copayment.Medicare Advantage Plans cover all Medicare servicesWhat is a Medicare health plan? A plan offered by a private company that contracts with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan. Medicare health plans include all Medicare Advantage Plans, Medicare Cost Plans, Demonstration/Pilot Programs, and Programs of All-inclusive Care for the Elderly (PACE).In all types of Medicare Advantage Plans, you're always covered for emergency and urgently needed care. Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care. Original Medicare covers hospice care even if you're in a Medicare Advantage Plan.The plan can choose not to cover the costs of services that aren't medically necessary under Medicare. If you're not sure whether a service is covered or not, check with your provider before you get the service.Medicare Advantage Plans may offer extra coverage, like vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D). In addition to your Part B premium, you usually pay a monthly premium for the Medicare Advantage Plan. Most people pay the Part B premium of $99.90 each month in 2012 ($104.90 in 2013).If you need a service that the plan says isn't medically necessary, you may have to pay all the costs of the service, but you have the right to appeal the decision.You can also ask the plan for a written advance coverage decision to make sure a service is medically necessary and will be covered. If the plan won't pay for a service you think you need, you'll have to pay all of the costs if you didn't ask for an advance coverage decision.MedicaidA state and federal partnership, Medicaid provides coverage for people with lower incomes, older people, people with disabilities, and some families and children. Learn more about the program in this section.What is Medicaid?Each state operates a Medicaid program that provides health coverage for lower-income people, families and children, the elderly, and people with disabilities.The eligibility rules for Medicaid are different for each state, but most states offer coverage for adults with children at some income level. In addition, beginning in 2014, most adults under age 65 with individual incomes up to about $15,000 per year will qualify for Medicaid in every state.How can I get Medicaid?You may be eligible for benefits through Medicaid. Medicaid programs vary by state, so you will need to check with your state Medicaid office for more information.∙Eligibility: People with disabilities are eligible in every state. In some states, people with disabilities qualify automatically if they get Supplemental Security Income (SSI) benefits.In other states you may qualify depending on your income and resources (financialassets).∙“Buy-Ins”:Some states also have “buy-in” programs that allow people with disabilities with incomes above regular Medicaid limits to enroll in the Medicaid program. Childrenwith disabilities can qualify for Medicaid either under these disability-related rules, orbased on family income.∙Expansion in 2014. Starting in 2014, the Affordable Care Act will expand the Medicaid program to cover people under age 65, including people with disabilities, with income ofabout $15,000 for a single individual (higher incomes for couples and families withchildren).∙Help for disabled people: This expansion helps low-income adults who have disabilities but don’t meet the disability requirements of the SSI program. The expansion also helpsthose whose income is above their state’s current eligibility levels.What does Medicaid cost?Medicaid coverage is designed to be affordable for everyone who is eligible. Cost sharing for Medicaid varies by state but is extremely limited for most participants.What does Medicaid cover?The benefits covered for adults through Medicaid are different in each state, but certain benefits are covered in every Medicaid program.Doctor’s services that are covered by Medicaid include:Laboratory and X-ray servicesInpatient hospital servicesOutpatient hospital servicesHealth screenings for children and treatment if medical problems are identifiedComprehensive dental and vision services for childrenFamily planning services and suppliesLong-term care services and supportsMedical and surgical dental services for adultsPediatric and family nurse practitioner servicesServices provided in health clinicsNurse-midwife servicesNursing facility services for adultsHome health care services for certain peoplePrescription drugsOther benefits your state must cover for children and may cover for adults:Physical, occupational, or speech therapyEye doctor visits, eyeglassesAudiology, hearing aidsProsthetic devicesMental health servicesRespite and other in-home long-term careCase managementPersonal care servicesHospice servicesThe Affordable Care Act will expand options for community-based care. There will be more opportunities for people of all ages who have a disability to get help with daily activities while remaining in their homes. The Medicaid program continues to move toward providing more community-based care options as an alternative to nursing homes.What special Medicaid coverage is available to women?Cancer Prevention and TreatmentBreast and Cervical Cancer Prevention and Treatment (BCCPT) Medicaid programs are available to eligible women who are diagnosed with either breast and/or cervical cancer through the state screening program. You may be eligible even if you have a higher income. States have flexibility to define what it means to have been diagnosed or screened under the program.Medicaid Options for Pregnant WomenPregnant women may have special eligibility for Medicaid coverage for themselves and their infants at little or no cost if they have limited income.Medicaid eligibility for pregnant women varies by state, but all states must cover pregnant women with incomes up to about $20,000 as an individual. Most states cover pregnant women under Medicaid with higher incomes, and some states cover pregnant women under the Children’s Health Insurance Program (CHIP).EligibilityMedicaid and CHIP provide health coverage to nearly 60 million Americans, including children, pregnant women, parents, seniors and individuals with disabilities. In order to participate in Medicaid, federal law requires states to cover certain population groups (mandatory eligibility groups) and gives them the flexibility to cover other population groups (optional eligibility groups). States set individual eligibility criteria within federal minimum standards. States can apply to CMS for a waiver of federal law to expand health coverage beyond these groups.Many states have expanded coverage, particularly for children, above the federal minimums. For many eligibility groups, income is calculated in relation to a percentage of the FederalPoverty Level (FPL). For example, 100% of the FPL for a family of four is $22,350 in 2011. The Federal Poverty Level is updated annually. For other groups, income standards are based on income or other non-financial criteria standards for other programs, such as the Supplemental Security Income (SSI) program.In accordance with CHIPRA section 213, CMS published a notice in Federal Register on December 18, 2009, (Vol. 74, No. 242) soliciting comments to assist in the development of a model process. CMS invites feedback from stakeholders regarding the viability of the proposal on interstate coordination.Affordable Care Act of 2010 Expands Medicaid Eligibility in 2014The Affordable Care Act of 2010, signed by President Obama on March 23, 2010, creates a national Medicaid minimum eligibility level of 133% of the federal poverty level ($29,700 for a family of four in 2011) for nearly all Americans under age 65. This Medicaid eligibility expansion goes into effect on January 1, 2014 but states can choose to expand coverage with Federal support anytime before this date-see related Federal Policy Guidance and states that have expanded Medicaid prior to 2014. See eligibility provisions in the Affordable Care Act.Other Eligibility CriteriaThere are other non-financial eligibility criteria that are used in determining Medicaid eligibility. In order to be eligible for Medicaid, individuals need to satisfy federal and state requirements regarding residency, immigration status, and documentation of U.S. citizenship.Retroactive EligibilityMedicaid coverage may start retroactively for up to 3 months prior to the month of application, if the individual would have been eligible during the retroactive period had he or she applied then. Coverage generally stops at the end of the month in which a person no longer meets the requirements for eligibility.Premiums, Copayments, & other Cost SharingStates have the option to charge premiums and to establish out of pocket spending (cost sharing) requirements for Medicaid enrollees. Out of pocket costs may include copayments, coinsurance, deductibles, and other similar charges. Maximum out of pocket costs are limited, but states can impose higher charges for targeted groups of somewhat higher income people. Certain vulnerable groups, such as children and pregnant women, are exempt from most out of pocket costs, and copayments and coinsurance cannot be charged for certain services.。

US Healthcare System

Inpatient Admissions in Community Hospitals
37 36 35 34 33 32 31 30 29 28 1980 1985 1990 1995 2000 2003 Millions
HOSPITALS
CHALLENGES
• Reposition philosophy, organization, facilities
LONG-TERM CARE
STATUS • SNF’s
– Declining occupancy last 15 years
• Older adults healthier • Vast increase in options • Federal prospective payment
– Will reverse with dramatic increase in numbers of “super-elderly” over next 25 years – Medicaid is largest payer
STAKEHOLDERS: THE PUBLIC • • • • Potential patients Taxpayers Purchasers of other goods and services Expectations?
– Is health care a right like public education or police protection?
LONG-TERM CARE
• Assisted living
– Rapid growth: expect to double by 2025 – Often part of retirement community – Private pay

USppt课件

口期内能达到完全缓解的患者其预后明显优于慢性病程患者，部分患者甚至有望完全停药。
常用RA病情活动度评估方法
缓解
低度活动
中度活动高度活动
SDAI≤3.3 3.3 ～ 11
11 ～ 26 >26
CDAI≤2.8 2.9 ～ 10
10 ～ 22 >22
DAS28≤2.6 2.6 ～ 3.2 3.2 ～ 5.1 >5.1
超声评估员
– 风湿病专家或是有经验的关节超声评估人员，无权限知道受试者的其它数据信息。在每次访视时，每一位受试者均由相同的关节超声评估人员进行评判。
观察指标
主要观察终点：
患者与医生均评估临床缓解时，两种维持治疗方案实现“超声缓解”的病人比例；
患者与医生均评估临床缓解时，双手及双腕关节 X线骨破坏进展。
肿胀关节数（SJC，以44个关节计数）压痛的关节数（TJC，以44个关节计数）健康评价（HAQ）:治疗前后由受试者对自己日常生活
能力包括穿衣、站立、吃喝、行走、卫生、抓握等20 项指标进行评估。评估分四级：0=无困难；1=有些困难；2=很困难；3=不能进行。受试者用10cm目视模拟标尺，对用药前后疾病综合状况做出评估医生对目前疾病状况的评估
患有除了类风湿关节炎以外其他风湿性自身免疫性疾病者：包括系统性红斑狼疮（SLE）、混合型结缔组织病（MTCD）、硬皮病、多肌炎。但伴有Sjogren综合征得受试者允许参加本实验。如果ANA阳性，应结合临床状态和抗DNA抗体试验阴性等排除受试者患SLE的可能。
手腕X光片分期为IV级的类风湿关节炎。曾经或正在患有除了类风湿关节炎以外的炎症性关节炎
B超评估
在研究药物首次给药前21天内完成筛选访视。在首次给药当天进行基线访视。

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STAKEHOLDERS: GOVERNMENTS
• DOMINANT PAYER (ABOUT 50%) – Medicare, Medicaid, VA
• HUGE REGULATOR
– Federal, State, Local
• DIRECT PROVIDER
– VA – State hospitals, clinics, health departments – County/City hospitals, clinics, health departments
0 U.S.
Norway Austria U.K.
Poland
1999
HEALTH CARE TRIANGLE
COST
QUALITY
ACCESS
Total U.S. Health Expenditures
1800 1600 1400 1200 1000
800 600 400 200
0
1965
1970
U.S. Healthcare System
• Overview in 90 minutes or less • Stakeholders • Major challenges
STAKEHOLDERS
• Patients/clients/customers • General Public • Employers • Governments • Insurance Plans • Providers
1873
178
1909 4,300
1946 6,000
1970’S 7,200
2000’S <4,000
HOSPITALS
STATUS • Losing money • Upward pressure on costs
– Critical staff shortages – Legislative/judicial mandates – Insurance premiums
STAKEHOLDERS: INSURANCE PLANS
FUNCTIONS • Develop coverage plans • Contract with providers • Market the plans • Underwrite • Manage utilization, quality, cost • Administer claims
• Increasing inpatient volume • Competition for outpatients
Inpatient Admissions in Community Hospitals
37 36 35 34 33 32 31 30 29 28
1980
1985
1990
1995
2000
STAKEHOLDERS: PROVIDERS
• HOSPITALS • OUTPATIENT CENTERS • PHYSICIANS • OTHER CLINICIANS • LONG-TERM CARE • MENTAL HEALTH • PUBLIC HEALTH
HOSPITALS
HISTORY
• When do they show interest?
Projected Growth in U.S. Population Age 65 and Older
70 60 50 40 30 20 10 0
1980 1990 2000 2010 2020 2030
Millions
STAKEHOLDERS: EMPLOYERS
STAKEHOLDERS: INSURANCE PLANS
KEY ISSUES • Control total cost
– Number of services used – Cost per unit of service
• Manage (shift) the risk • Satisfy consumers, regulators, courts
2003
Millions
HOSPITALS
CHALLENGES
ቤተ መጻሕፍቲ ባይዱ
1980
1990
2000
2005
$ Billions
STAKEHOLDERS: THE PUBLIC
• Potential patients • Taxpayers • Purchasers of other goods and services • Expectations?
– Is health care a right like public education or police protection?
• Pay most of the private insurance premiums • Taxpayers • Competing for workers • Competing globally for markets • >10% premium increases • How are they coping?
STAKEHOLDERS: INSURANCE PLANS
STATUS • Cyclical profit and loss • Return to rapid premium increases • Consolidation • Backlash against controls
– Consumers – Politicians – Courts
CHANNEL OF DISTRIBUTION INPATIENT SURGERY
CONSUMER
EMPLOYER INSURER PCP
SURGEON HOSPITAL
PER CAPITA HEALTH EXPENDITURES
4500 4000 3500 3000 2500 2000 1500 1000 500
• POLITICS
STAKEHOLDERS: INSURANCE PLANS
EVOLUTION • 1930’s—Blue Cross • POST WW2—Rapid growth of employer based
plans • 1980’s—Managed Care • Integrated networks