《JEFF资料库》-公共管理-美国医疗保险制度(精品·公开课件).ppt

LOGO LOGO US Health Care System Jeff Cheung The Department in charge The details in management US Health Care Spending Three Main Parties in Health Care Payer 支付方 Service Provider 服务提供方 Patient 患者 Providers Doctors Hospitals LaboratoriesMEC Pharmacies(Drugstore) Pharmaceutical Companies (formularies) Home care and other specialty care What Do Providers Do? Family doctors: one-to-one relationship Specialists: specialty care Hospitals: inpatient and emergency care Drug stores: drug prescriptions Pharmaceutical companies: drugs under a “formulary” arrangement What Do Patients Do? Uninsured: seek emergency care or Medicaid Insured: Choose a family doctor Family doctor becomes the “care manager” Family doctor must make referral（转诊病人） to hospitals Make co-pay as defined by payers (office visits, generic / brand name drug, out-of-pocket maximums, etc.) Payers Government: Medicare and state Medicaid programs Health insurance programs / HMO Patients What Do Payers Do? Pay claims submitted by providers. Establish “reasonable and customary” fee schedule. Provide contracts based on price and quality. Manage care through pre-authorization, referrals（推荐）, case management, and preventive care（预防性护理）. People stay healthy Diseases are diagnosed early Minimize disease complications（并发症） What benefits health insurance companies Health Insurance Companies Keep Provider Costs Down Physician contracting Hospital contracting Formulary This removes all “extra benefits” from providers and allow health insurance companies to, in theory, pass the benefits to consumers. 这排除了服务提供方的“额外收益”，而将此利益让渡给医疗保险公司，理论上说，是消费者受益。 A Private Third Party Payer is the key to keep US Health Care System in Balance Competition after Privatization Providers must compete for Payer business. Payers must compete for Patient business. Each market must have multiple Payers (A, B, and C insurance companies) Each market must have multiple Provider networks. Compete on both pri