PH 150D Midterm Review

October 16, 2014

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 Commonwealth Policy Brief 2009
o Pauly and Pagan 2007
o Gusamno et al 2002
o Aragon 2001
o Gawande 2009
o Schroeder 2007
o Mechanic and Tanner 2007
o Health Leaders Survey 2014
o American Hospital Association 2011

Outline:
1. Introduction (8/28)
2. Health Care in the US (9/2, Barr, Chapters 2 & 3; Orszag;
Cutler)
3. Health Coverage: Employer Based Insurance (9/4, Barr,
Chapters 5 & 8)
4. Health Coverage: Individual Market (9/9, Commonwealth Policy
Brief)
5. Health Coverage: Public Programs - Medicare (9/11, Barr,
Chapter 6)
6. Health Coverage: Public Programs Medicaid (9/16, Barr,
Chapters 7)
7. The Uninsured (9/18, Barr Chapter 11; Pauly-Pagan; Gusmano
et al)
8. Stakeholders (9/23, Barr, Chapter 4, link)
9. Health Advocacy and the Legislative Process (9/25, Aragon)
10.
Quality of Care (9/30, Gawande)
11.
Putting the H in HPM (10/2, Schroeder; Mechanic and
Tanner)

Concepts:
1. Introduction (8/23)
2. Health Care in the US (8/30, 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 (9/4, 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
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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 (9/9, 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 (9/11, 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
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vi. Part D: Doughnut hole

6. Health Coverage: Public Programs - Medicaid (9/16, 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 (9/18, 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 (9/23, Barr, Chapter 4)
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
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vi. Governments
vii. Other (e.g., nonprofits, foundations)
9. Health Advocacy and the Legislative Process (9/25, Aragon)
a. Advocacy types/strategies
i. Legislative, administrative, media, policy research,
community-organizing
10.

Quality of Care (9/30, Gawande)

a. What is quality of care
b. Evidence-based medicine
c. Relationship between quality and spending
i. Regional variation in spending

11. Putting the H in HPM (10/2, Schroeder; Mechanic and

Tanner) (NOTE: This will be different, because this was done
as a guest lecture in the fall, but Professor Flagg is lecturing
on this in the summer, so use Professor Flaggs slides as a
guide.)
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