Nationally, the health care industry is undergoing unparalleled restructuring. This movement is characterized by rapid mergers, consolidation among those providing health care, and a blurring of the previous distinctions between providers and insurers. Much of this restructuring also involves putting in place a new set of incentives, payment mechanisms, and quality measures. Thus, the health care market in which providers and consumers operate is changing. Four areas in which Extension can play a part are managed care, access to care (facilities and providers), consumer knowledge of health plans, and the changing role of insurance.
Managed Care
The proposed managed care systems place greater emphasis on "capitated" payments.
Proponents of "managed care" believe it will slow the growth of national health care
expenditures and create incentives for healthy behaviors and lifestyles. Others are
skeptical of this claim, arguing that any savings will be at the expense of quality and/or
access. Local consumers and health care providers have much at stake.
Since the managed care movement is further along in many other states, Nebraska can benefit greatly from the lessons being learned elsewhere. By working together, local citizens, providers, and communities can chart a future course of action to meet their collective interests.
Access To Care (Facilities and Providers)
The reimbursement structure for health care facilities is changing. A hospital's ability to
survive or even stay technologically current threatens adequate access to health care. As
costs begin to exceed revenues, hospitals are struggling to make financial ends meet.
Occupancy rates continue to decrease as more procedures occur on an out-patient basis
and allowable hospital stays become shorter. The cost of new technology is financially
problematic for many hospitals.
Between now and the year 2000, cutbacks in Medicare will impact rural hospitals who now rely on this funding for survival. A community may be forced to choose between closing its hospitals or dramatically increasing hospital subsidies. Other proposed changes at the federal level may put additional stress on the local economy's capacity to support local services, e.g., changes in farm programs, Medicaid, and welfare.
The number of Nebraskans age 85 and older has grown. Nebraska now ranks as one of the top five states for percentage of persons in this age group. Availability of services including long-term care is important. Although the incentive to provide long term care exists, providing a full array of services is not feasible. Problems include: the high cost of nursing home care; rural hospitals are distressed; a lack of non-emergency transportation services; and community based long-term care options are limited.
To exacerbate the issue, there is a shortage of health care providers. The shortage is particularly prevalent with primary care physicians, physician assistants, nurse practitioners, nurse midwives, psychiatrists, and psychologists. There is also a shortage of allied health professionals such as physical and occupational therapists.
Consumer Knowledge of Health Plans
According to the Consumer Expenditure Survey, expenditures by all parties on health
insurance surpassed spending on medical care services in 1990. The true cost of health
insurance is difficult to ascertain due to the sharing of health care coverage costs by
employers, government, and consumers. However, it is clear that the total share of
household spending allocated to health care has risen. Between 1984 and 1992, several
changes in responsibility for health care coverage were documented. Consumers are
paying higher copayments and higher proportions of health insurance premiums than in the
past. In an effort to reduce the spiraling costs of health care, the use of managed care
plans such as health maintenance organizations, preferred provider organizations, and
other prepaid plans of medical care coverage is on the increase.
During the same time period, an increasing number of persons were uninsured or underinsured. By definition, being underinsured occurs when insurance held does not match need. Little is known about the condition of underinsurance and, separately, the area of comprehension of health care coverage. However, the speculation is that failure to select appropriate coverage is due to lack of understanding of insurance products. It appears, also, that consumers learn about their coverage through trial and error. As the amount of information available on which to select providers improves, the number of payment options increases or changes, and delivery of health care becomes a shared system, the importance of consumers' understanding of health care plans will become more crucial in the quality of health care received.
Role of Insurance
In Nebraska, there are approximately 190,000 persons of the under age 65 population
without health insurance. The proportion of the state's population that is uninsured has
increased in recent years to 13.7 percent. The underlying cause of much of the
uninsurance is affordability--especially for those with limited resources, but who are not
poor enough to qualify for Medicaid. However, other factors contribute to uninsurance,
e.g., individuals may have pre-existing conditions or may have a lapse in coverage between
jobs. Additionally, those who are self-employed or who employ a small number of
workers often face very high premiums. Some young adults may choose not to spend
money on health insurance. Both employers and insurance companies are increasingly
reluctant to provide behavioral health coverage (mental health, substance abuse, and
addiction services).
State insurance regulations define what minimum benefits an insurance product will hold. Self-insured employers fall under different rules (due to exemptions under ERISA). These regulations are being challenged within various states. As the discussion moves toward requiring insurance companies to enroll anyone, including those with pre-existing medical conditions, trade-offs will have to occur. Various groups should provide input as to what trade-offs are fair.
IANR Theme/Cooperative Extension Issues
This issue area supports the IANR long-term program theme objective to strengthen the quality of life of individuals and families and contribute to community viability. It also supports the Nebraska Cooperative Extension Strengthen Nebraska Communities; Children, Youth and Families; Food Safety and Quality; Water Quality and Environment; and Agricultural Profitability and Sustainability issues.
Anticipated Outcomes
Central Outcome: Nebraskan's will become more knowledgeable about changes underway in health care delivery and finance as well as the issues and implications associated with these changes.
Managed care
Access to Care
Consumer Knowledge of Health Care Plans
Role of Insurance
Evaluation Plan
General Outcome
Focus
Awareness and knowledge about system changes, and associated issues and implications.
Framework
Evaluative questions would focus on knowledge about different models for organizing, financing,
and delivering care; the characteristics of each system; knowledge of health policy goals (access,
quality, and cost); and current knowledge about public and private policy changes and how
they affect access quality, and cost.
Outcomes for Managed Care
Focus
1. Improved assessment and understanding of impacts by those considering managed care.
Framework
Evaluative questions would focus on knowledge of the managed care system for health care
finance and delivery (its characteristics and variation) and the techniques and framework for
assessing its likely impacts in any particular locale and its citizens.
Focus
2. Good decisions and a responsive and appropriate system for those who choose managed care.
Framework
Consumers and key leaders in communities reached by Extension programming that opt for
a managed care system would be asked to assess whether their local health system has
improved or not. Criteria or areas of inquiry would focus on number of providers available,
scope of services provided, waiting time, cost, and satisfaction with care received.
Outcomes for Access to Care
Focus
1. Greater understanding of larger societal role of the health sector.
Framework
Evaluative questions would focus on knowledge about the role and relationship of the local
health sector to other local institutions, for example, the number of local jobs associated with
the sector, and the level of Medicare payments that flow into the local economy.
Focus
2. Increased multi-community discussion and planning.
Framework
Selected communities that rely on Extension assistance in helping to improve access to care
will be analyzed. Secondary data may be available to help with the assessment.
Additionally, residents or key informants would be asked about changes in access
indicators (e.g. number of providers, distance to nearest provider, availability of mobile
services or telemedicine, etc.).
Outcomes for Consumer Knowledge
Focus
1. Increased consumer empowerment when using health services.
Framework
Consumers would be asked about their ability and effectiveness in questioning and
interacting with health care providers or systems, using outcome data, and related
aspects of consumerism.
Focus
2. Those with insurance will read and understand plans, and make appropriate
selections and adjustments.
Framework
Those reached by Extension programming would be asked if they have read their
insurance plans, are they now more knowledgeable about their coverage, and
whether or not they made any changes because of the educational program they
received.
Outcomes for Health Insurance
Focus
1. Improved understanding of system-wide relationship among coverage, choice, and
cost containment as changes in health insurance occur or are considered.
Framework
Evaluative questions would focus on knowledge of the impact of (a) portability of
coverage, (b) prohibiting pre-existing condition clauses, (c) community versus
experiential rating, and (d) other insurance changes on total cost, distribution of costs and
benefits, behavioral response to insurance changes, and level of insurance coverage that
results.
Focus
2. Greater citizen involvement in debate and discussion as changes in health insurance
occur or are considered.
Framework
Measure of citizen involvement would include attendance and participation at public and
legislative forums, requests by citizens for information, and number of letters to the
editor and to the policy arena.
Educational Program
Program Ends
This program is designed as a four year project. However, the program will be updated as needed to reflect the emerging health care issues as they arise.
Health Care in Transition Writing Team
Mary Ellen Rider, Co-chair - UNL Family and Consumer Science
Sam Cordes, Co-chair - UNL Agricultural Economics
Lorene Bartos - UNL Cooperative Extension - Lancaster County
Ken Burgert - UNL Cooperative Extension - Johnson, Nemaha & Pawnee Counties
Marilyn Fox - UNL Cooperative Extension - Hall County
Jessye Goertz - UNL Cooperative Extension - Scotts Bluff/Morrill Counties
Keith Mueller - UNMC Department of Preventive & Social Medicine
David Palm - Nebraska Department of Health
Carol Plate - UNL Cooperative Extension - Brown, Rock & Keya Paha Counties