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PH 150D Midterm Review October 15, 2015 This review sheet covers themes and concepts from the readings and lecture for which you should know the definition and significance for U.S. health policy 

Key readings that we expect you to be able to recall and cite: o Orszag and Ellis 2007 o Cutler et al 2006 o Blumenthal o Commonwealth Policy Brief 2009 o o o o o o o

Pauly and Pagan 2007 Gusamno et al 2002 Aragon 2001 Gawande 2013 Chassin 2010 Schroeder 2007 Health Leaders Survey 2014

Outline: 1. Introduction (8/27) 2. Health Care in the US (9/1) 3. Health Coverage: Employer Based Insurance (9/3) 4. Health Coverage: Individual Market (9/8) 5. Health Coverage: Public Programs - Medicare (9/10) 6. Health Coverage: Public Programs – Medicaid (9/15) 7. The Uninsured (9/17) 8. Stakeholders (9/22) 9. Quality of Care (9/24) 10.Putting the “M” in HPM (9/29) 11.Putting the “P” in HPM (10/1) 12.Putting the “H” in HPM (10/6) 13.Health Advocacy and the Legislative Process (10/8)) 14. Hospitals (10/13)

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Concepts: 1. Introduction (8/27) 2. Health Care in the US (9/1, Orszag, Cutler) a. Culture/Values/Institutions that underpin our health care system i. Market Justice vs. Social Justice & Implications ii. Why market failure is common health care markets b. Cost of Care i. Trends in spending/costs 1. Impacts on public and private payers 2. Main drivers of health care spending ii. Relationship between spending, health outcomes, and quality of care 1. Value for medical spending? 3. Health Coverage: Employer Based Insurance (9/3, Barr, Chapters 5 & 8; Blumenthal) a. Basic definitions i. Premium ii. Deductible iii. Co-payments iv. Co-insurance v. Out-of-pocket payments b. Payment Systems i. Capitation ii. Fee for service (FFS) KEY: Know how different payment systems shift financial risk; change provider/facility incentives, and influence the quality of care. c. History of Insurance in the US i. Indemnity plans ii. Experience rating d. Employer-Based Insurance i. “Accident” of History: Employer-Based Coverage ii. Health Care as a Fringe benefit iii. Employee Cost-Sharing (see part 3a above) iv. Gaps: why a person might not be able to get it e. Managed Care i. HMO ii. Preferred provider organizations (PPOs) f. Utilization Controls: Ways care is “managed” 2

i. Gatekeepers ii. Networks of Contract Physicians iii. Utilization Review iv. Physician Practice Profiles v. Financial incentives g. Medical Loss Ratio 4. Health Coverage: Individual Market (9/8, Commonwealth Policy Brief) a. Definitions of Insurance i. Random hazard ii. Risk pooling iii. Moral hazard iv. Adverse selection b. Individual Market i. How it differs from Employer-Based Coverage (also known as Group Market) 1. Underwriting: Community vs. Individual Rating 2. “Cherry picking” (avoid adverse selection) 3. Different incentives for individuals and insurers 4. Paradox: Why some might not be able to get individual market insurance c. Three-legged stool i. Guaranteed Issue ii. Mandate iii. Assistance (information and subsidies) 5. Health Coverage: Public Programs - Medicare (9/10, Barr, Chapters 6) a. Medicare i. Different components (Parts A, B, C & D) and who and what they cover ii. How financed (who pays) iii. Payment systems 1. Diagnosis-related group (DRG) or prospective payment system iv. Gaps: why a person might not be able to get it. Things not covered. v. Current Issues in Medicare: 1. Long-term viability vi. Part D: Doughnut hole

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6. Health Coverage: Public Programs - Medicaid (9/15, Barr, Chapters 7) a. Medicaid i. Who and what is covered ii. Who is responsible for management iii. How is it financed: FMAP, FPL iv. Gaps: why a person might not be able to get it. Things not covered v. Variation of Medicaid programs across states 1. Mandatory and optional benefits 2. Different decisions on who and what to cover, who delivers services, and reimbursement rates b. SCHIP i. Who is covered? ii. Relationship with Medicaid 7. The Uninsured (9/17, Barr Chapter 11; Pauly-Pagan; Gusmano et al) a. Uninsured i. Limitations of Employer-Based Insurance, Individual (self-purchased) Insurance, and Public Insurance (Medicaid, Medicare) ii. Who are the uninsured? iii. Cost of uninsured iv. Who pays for their care? 1. Cost shifting v. Impact on health care quality & cost 1. Spillovers (financial and nonfinancial) b. Who are the “safety net” providers for the uninsured? 8. Stakeholders (9/22, Barr, Chapter 4, link) a. Healthcare Stakeholders i. Providers: Physicians, Nurses, Other Practitioners 1. Scope of practice ii. Purchasers (e.g., health plan) iii. Manufacturers (e.g., pharmaceutical industry) iv. Patients/Consumers v. Businesses vi. Governments vii. Other (e.g., nonprofits, foundations)

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9. Quality of Care (9/24 Gawande, Chassin) a. What is quality of care b. Evidence-based medicine c. Relationship between quality and spending i. Regional variation in spending 10.Putting the “M” in HPM (9/29, Health Leaders Survey, S&P) a. Core Management Disciplines b. SWOT analysis 11. Putting the “P” in HPM (10/1) a. 3 Ps b. For any health care policy, identify i. The stakeholders and their interests/agendas ii. How they would frame the issue based on their stakes/agendas c. Lowi: Policy driving politics i. Types of policy: Wilson’s typology d. Lindblom: Politics driving policy e. The ‘confluence’ of three streams (problems, policies, politics: 3 Ps) necessary to get issue on agenda (Kingdon) 12.Putting the “H” in HPM (10/6, Schroeder; Adler) a. What is “health”? i. Public health vs. health care b. Proportional contribution to premature death i. Medical care (10%), social circumstances, lifestyle/behavior, genetic predisposition, environmental factors c. Social determinants of health d. Health disparities e. Equity vs. equality 13.Health Advocacy and the Legislative Process (10/8, Aragon) a. Advocacy types/strategies i. Legislative, administrative, media, policy research, communityorganizing 14.Hospitals (10/13, Barr pp. 72-77, American Hospital Association) a. Nonprofit vs. profit hospitals 5...