SAN DIEGO STATE UNIVERSITY
College of Health and Human Services
Graduate School of Public Health
Division of Health Management and Policy
PH 742B: Health Insurance and Financing Systems
Fall 2011
3 Units
Day:
Time:
Location:
Schedule No.:
E-mail:
Office Location:
Monday
1600-1840
COM-206
22339
akoch@mail.sdsu.edu
HT-154
Instructor:
Alma L. Koch, Ph.D.
Office Hours:
By appointment. Available
evenings & weekends, and regular hours.
Office Phone:
(619) 594-5698
Home Phone:
(619) 286-5229
COURSE DESCRIPTION
U.S. healthcare financial systems at the macro-level. Overview of the 2010 Patient Protection
and Affordable Care Act (aka Health Reform). Principles of public programs and private health
insurance, types of reimbursement for healthcare organizations and providers, issues of cost
containment, effects of uninsurance and underinsurance, and financial practices of other
advanced nations.
COURSE COMPETENCIES & LEARNING OBJECTIVES:
The Division of Health Management & Policy is accredited by the Commission on Accreditation
Healthcare Management Education (CAHME). Refer to the GSPH website and Blackboard HR140 for more details and a full listing of our CAHME program competencies. Following are the
competencies that PH 742B fulfills.
Competency A1: Discuss heath care organization and its relationship to access, quality cost
resource allocation, accountability, and the health of patients and the community.
Competency A2: Describe trends in health care expenditures, causes, and consequences on
health and healthcare management.
Competency A4: Identify revenue sources and reimbursement methods in the U.S. healthcare
system, including historical origins and current policy.
Competency A5: Compare and contrast various healthcare delivery models, including verious
forms of managed care and fee-for service.
Competency A6: Relate health disparities, lack of insurance, and changes due to health care
reform to the challenges posed by delivering health care services to diverse populations.
Competency A7: Describe the roles of legislation, and governmental , regulatory, professional,
and/or accreditation agencies, including current legislative issues, in the U.S. healthcare system.
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Competency C5: Describe the market characteristics of provider organizations from an
economic perspective.
Competency C9: Describe formulas and strategies used by healthcare organizations and the
government for cost containment and revenue enhancement especially for Medicare and
Medicaid.
Competency C11: Compare alternatives for health care transformation and reform in the U.S.
with other countries and individual state initiatives.
Competency E4: Apply medical and business ethics to aid in decision making and analysis of
health care problems and issues - expecially access, quality, and the cost of care.
COURSE GOALS AND LEARNING OBJECTIVES [CAHME Competencies in brackets]
By the end of this course, the student will be able to:
1. Describe the 2010 Patient Protection and Affordable Care Act (i.e., the health reform act) and
its probable financial effects, both short term and long term, on critical aspects of health care
in the U.S. [A1, A3, A6, A11, C5, C11, E4]
2. Discuss major topics in financing national health systems, comparing the American system to
other approaches used internationally to finance health services. [A11, C11]
3. Critique traditional strategies for financing a health care system. [A2, A4, A5, A6, A7, E4]
4. Compare, contrast, and analyze reimbursement principles and procedures for financing health
services, including:
a. General health insurance concepts, [A1, A4, A6]
b. Differentiation among types of health insurance—voluntary (i.e., private), social, and
welfare, [A1, A2, A6]
c. Tax policy, party politics, and their relationships to health financing, [A7]
d. Precepts of Medicare and Medicaid, including major laws and regulations, [A4, A7, C5,
C9]
e. Reimbursement modalities and monetary incentives embedded in health insurance
strategies, and their ethical consequences, [A6, C4, E4]
f. Monetary incentives embedded in health insurance strategies, [ A4, C9]
g. Pay for performance, [ A4, A7, C9]
h. Financial organization of managed care, in its various manifestations, [A5]
i. The idea of establishing global budgeting for health services. [A2, A3]
5. To distinguish among various public and private methods for financing health services by
setting and provider type, both inpatient and ambulatory, [A2, A3, A4, A5]
7. To apply the principles of insurance in choosing a health insurance plan, as part of a written
assignment. [B2, E4]
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8. To intelligently discuss major health care financing issues of the day including, but not
limited to health reform, cost containment strategies, humanitarian considerations, and
evolving reimbursement schemes, such as the Medicare prescription drug benefit and IPPS
“pay for performance” measures, and Accountable Care Organizations. [A1, E4]
Prerequisites: PH 742A or the equivalent
READINGS:
Stephen J. Williams and Paul R. Torrens, Introduction to Health Services, 7th Edition. Chapters
4 and 5. Note that this is the 2007 edition. The first few weeks of the course will cover these
chapters in depth. For those who no longer have this edition of book, a draft copy of the updated
chapters will be made available on Blackboard.
Journal articles and other readings will be copied from various sources. Readings are uploaded
on Blackboard. Because of U.S. Health Reform, updates to the readings are expected. Details
will be forthcoming in class and on Blackboard.
Copies of Classroom-Use Materials
The slides used in lectures will be distributed at regular intervals in PDF files via Blackboard.
GRADING:
Two examinations - a midterm and a final - will be administered. One written assignment
dealing with health insurance selection will be required. The grading will be calculated as
follows:
Midterm Examination
Final Examination
Assignment
Total
35%
35%
30%
100%
HEALTH INSURANCE SELECTION ASSIGNMENT
Due: Monday, November 28, 2011
Choose an individual health insurance policy. Here is the scenario. You are working in San
Diego for a small employer in health care, with only 24 employees to insure. Your organization
is making enough money and everyone wants health insurance, including the owner. The
organization is besieged by lousy deals from "iffy" insurance brokers. In a fit of kindness, your
employer announces the following plan. This is based on sales/marketing available on the
internet directly from Blue Cross or Kaiser.
Every employee may purchase an individual comprehensive insurance policy from either Blue
Cross or Kaiser. The employee may insure his/her spouse, legal domestic partners, and children
(or the employee only). The company will pay 50% of the monthly premium up to $300 a month,
whichever is lower. For example, if you choose a plan with a $350 premium per month, the
company will pay $175 and you will pay $175. If you choose a plan that is $625 per month, the
company will pay $300, and you pay $325.
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You are insuring for general health only, including prescription drugs. No dental, no vision. You
may choose any individual plan that you want, even catastrophic (if it makes sense financially).
You may choose any individual plan from Kaiser or Blue Cross. Here are the web addresses to
use:
http://www.kaiserpermanente.org/
http://www.bluecrossca.com/
You will not use any brokers unless instructed to by the Blue Cross or Kaiser websites.
Write an assessment of your selection, evaluating the following factors:

Size and composition of your family as of 01/01/09. Or you may invent a “fantasy
family” or project your presumed family composition a few years into the future. Just
make it clear that you have done so. However, if you create an outlandish example,
and say that you are making $300,000 in your first job, and can afford anything, think
again.

Anticipated health/medical needs and risk factors.

Financial factors including (1) the premium price of the plan per month and per year
(2) anticipated copayments and deductibles, (3) and the net cost to you (i.e., the total
cost minus the employer contribution). You must display the differences among costs
for three plans selected. Tables are nice, especially if they are well organized.

The location of providers, including hospitals and physicians. Please be sure to select
a plan for your expected area of residence in San Diego County. (Kaiser may not
cover every zip code.)

The features of the plan, including benefits, copayments, and any other factors that are
important to you.

The reputation of the health plan, including timeliness of referrals, reimbursements to you
(if applicable).

Features of unselected plans that turn you off (for example, benefits that you'd just as
soon not pay for).
Written Assignment: Discuss your general criteria for selection. Then choose three plans for
further research and comparison. Briefly discuss your reasons for choosing these three plans in
the first place. Then select one plan, giving detailed reasons why you chose this plan over the
others.
You can choose any plan available in your area. The 3 plans that you choose to compare may
affect your grade. For example, you can choose one HMO and compare the various premium
options. But if you take this route, the assignment may not be challenging (that is, worthy of a
high grade), especially if the decision is a no-brainer. Extending the example, it would not be
much of a challenge for a 25 year old, healthy, single woman to choose a the cheapest Kaiser
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plan and take her chances on staying healthy—not mounting up out-of-pocket payments). So try
comparing HMO plans offered by both companies, or compare the HMO to the PPO or the MSA.
You are not allowed to take any gambles that you can’t cover with money. If you choose a lowpremium PPO plan with a high deductible and high copayments, you must have access to the
money to cover the deductible and activate the policy. In other words, you must convince me that
this is a sound choice that you can cover financially. Medicare Savings Accounts (MSAs fall in
this category.)
Suggested length: 5 double-spaced pages. Needlessly long papers will be downgraded.
*Any real life health factors or “fantasy family” details that you wish to include will be kept in
strict confidence. With that said, don’t disclose any deep, dark secrets that should remain
confidential—secrets that you should discuss only with your physician or attorney, for examples.
GRADING SCALE FOR COURSE
Total Points
Assigned Grade
94-100
A
90-94
A-
87-89
B+
84-86
B
80-83
B-
77-79
C+
74-76
C
70-73
C-
F
<70
Course Syllabus Subject to Change
Every effort will be made to follow the syllabus content and schedule; however, if circumstances
dictate there may be modifications necessary during the semester. If such is the case, the
professor will notify students via Blackboard.
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COURSE CALENDAR
Week
1
2
3
4
5
6
7
8
Date
08/29
09/05
09/12
09/19
09/26
10/03
10/10
10/17
9
10
11
12
13
14
10/24
10/31
11/07
11/14
11/21
11/28
15
12/05
16
12/12
Topic
Introduction to Health Insurance
LABOR DAY: No Class
Actuarial Principles of Health Insurance
Health Spending and Cost Containment
Social Health Insurance
Private Health Insurance
Health Reform Act of 2010, Financing health reform
MIDTERM EXAMINATION; Film #1: Who Pays for Mom and
Dad? Long-Term Care Financing Principles
Medicare Financing Principles
Medicare Pay for Performance, HMO Reimbursement
Medicaid Benefits and Financing Principles
Medicare Physician Reimbursement
Financing Health Reform
Health Insurance Selection Assignment Due. MD Reimbursements
Systems Worldwide
Single Payer Systems with Global Budgeting, International Financing
Systems
FINAL EXAMINATION 1600-1800
Required Readings by Week and Topic (Subject to Revision)
Wk
1
2
3
Topic
Introduction to Health Insurance:
risk, moral hazard, selection bias.
Introduction to the Patient
Protection and Affordable Care Act
Health Reform Act of 2010
LABOR DAY
Readings
CAHME
Competency
”Financing Health Services,” Williams A2
and Torrens, Introduction to Health C5
Services, 7th Edition, 2007, Chapter 4.
C11
E4
No Class
Actuarial Principles of Health
Chapter 4 continued.
Insurance; Social Health Insurance:
revenues, premiums, ratings, equity,
individual vs. group risk
assessment.
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A1
A4
C5
4
5
6
Health Spending and Cost
Containment: national health
expenditures, revenue contributors,
provider expenditures, major dollar
trends in health insurance. Public
vs. private sector trends vs.
overarching social goals. Basic
methods of reimbursement.
Micah Hartman, et al. Heath Spending
Growth at a Historic Low in 2008.
Health Affairs, January 2010.
Social Health Insurance: Principles
of Taxation, Social Security
principles, Medicare
Reimbursement Principles and
Benefits
Private Health Insurance:
Taxonomies, revenue distribution,
uninsurance and underinsurance
trends and causes
Chapter 4 continued
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Patient Protection and Affordable
Care Act Health Reform Act of
2010: Sequencing of funding and
insurance changes. Accountable
Care Organizations.
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Midterm Exam;
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10
A1
A2
E4
Henry J. Aaron, “Should Public Policy
Seek to Control the Growth of Health
Care Spending?” Health Affairs,
January 2003, W3 28-36.
Medicare and You, 2010.
A1
A5
A7
C9
”Health Insurance,” Williams and A1
Torrens, Introduction to Health A2
Services, Chapter 5.
A4
A6
E4
A1
Compilation of the Act (974 pages for
A2
reference)
C11
E4
Issue briefs from Kaiser Family
Foundation
Film, "Who Pays for Mom and
Dad? Long-Term Care Financing
Principles and their ethical and
social consequences.
Medicare Reimbursement
Chapter 4, pp. 97-101
Principles: Medicare Inpatient
Prospective Payment System
(IPPS),various provider payment
schemes and formulas. Relationship
to Federal health reform
reimbursement and other state
models.
Medicare HMO payment, Medicare P4P article TBD.
Pay for Performance
Randall S. Brown, et al. Do Health
Maintenance Organizations Work for
Medicare? Health Care Financing
Review, 15(1):7-23. Fall 1993.
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A1
A7
E4
C9
C11
A5
A7
C5
11
Medicaid Financing and Benefits;
Relation to Health Reform
Chapter 4
Readings from CMS
A5
A7
C9
C11
12
Medicare Physician
Reimbursement: Resource Based
Relative Values.
Hsiao, William C., et al., “Results and
Impacts of the Resource-Based
Relative Value Scale.” Medical Care,
30(11):NS61-NS79. November 1992.
A1
A6
C9
E4
Levy, Jesse M. et al., “Understanding
the Medicare Fee Schedule and its
Impact on Physicians Under the Final
Rule.” Medical Care, 30(11):NS80NS94. November 1992.
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Organizing Health Reform:
Accountable Care Organizations.
Kaiser Family Foundation: Assorted
Issue Briefs
A1
C5
C11
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MD Reimbursement Systems and
their relationship to the continuum
of managed care.
Chapter 5, Section on Managed Care &
HMOs
Reinhardt, Uwe E., “The Compensation
of Physicians: Approaches Used in
Foreign Countries.” Quality Review
Bulletin, pp.366-377. December 1985.
A1
A4
A5
A7
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Single Payer System with Global
Budgeting: Germany
Reinhardt, Uwe E., “West Germany’s
Health Care and Health Insurance
System: Combining Universal Access
with Cost Control” A Call for Action:
Final Report of the U.S. Bipartisan
Commission on U.S. Health Care.
Washington, D.C., U.S. Government
Printing Office, September 1990. pp. 316.
Reinhardt, Uwe E., “Global Budgeting
in German Health Care: Insights for
Americans.” Domestic Affairs, pp.
159-194. Winter 1993/94.
C11
E4
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COURSE POLICIES
Missing class. A student who is unable to attend a lecture should get impeccable notes from
another student or a tape of the lecture. Readings may support or refute material given in lectures,
and without lecture notes, you won’t know what is what. If you miss a class, it is your
responsibility to contact the instructor, to obtain lecture notes, handouts, other materials or
instructions from the course Blackboard site or a classmate.
Missing an Examination. Examinations will never be given in advance of the scheduled date and
time of the exam. In extenuating circumstances, makeup examinations will be administered as
soon as possible. In the case of final examinations, a student missing the exam may be given an
“Incomplete” grade until the exam is made up.
Religious holidays The University Policy File includes the following statement on absence for
Religious Observances: “By the end of the second week of classes, students should notify the
instructors of affected courses of planned absences for religious observances.”
Testing. Once a test begins, students are not to leave the classroom until he or she has completed
the examination. Needs should be attended to prior to the examination. The Final Examination
will not be comprehensive per se, but the student is expected to know basic material in the first
part of the course in order to understand and answer questions on the final exam.
Extenuating circumstances. If severe difficulties (e.g., illness, injury, death of a family member)
prevent you from completing an assignment on time, please contact the instructor to discuss
alternative arrangements.
Computers. Every student must have access to the internet and a computer in order to obtain
communications from the professor, download reading material and conduct document searches
of on-line publications.
Safety. Students are encouraged to consult with SDSU public safety regarding parking and other
safety issues. Late at night, students are encouraged to walk to their destinations in groups of two
or more.
Academic misconduct by a student shall include, but not be limited to: disrupting classes; giving
or receiving unauthorized aid on examinations, reports or other assignments; knowingly
misrepresenting the source of any academic work; falsifying research results; plagiarizing
another’s work; violating regulations or ethical codes for the treatment of human subjects; or
otherwise acting dishonestly. If an instance of academic misconduct is suspected, the student will
be informed of the infraction and the penalty to be imposed. If appropriate, the matter will be
referred to the Director of the GSPH and Assistant Dean of the College of Health and Human
Services for mediation. Potential sanctions include a warning, an admonition, censure, reduction
of grade (including a grade of F for the course), disciplinary probation, suspension, or expulsion.
Statement on Nondiscrimination Policy
San Diego State University complies with the requirements of Title VI and Title VII of the Civil
Rights Act of 1964, as well as other applicable federal and state laws prohibiting discrimination.
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No person shall, on the basis of race, color, or national origin be excluded from participation in,
be denied the benefits of, or be otherwise subjected to discrimination in any program of the
California State University
SDSU does not discriminate on the basis of disability in admission or access to, or treatment or
employment in, its programs and activities. Students should direct inquiries concerning San
Diego State University’s compliance with all relevant disability laws to the Director of Student
Disability Services (SDS), Calpulli Center, Room 3101, San Diego State University, San Diego,
CA 92128 or call 619-594-6473 (TDD: 619-594-2929).
SDSU does not discriminate on the basis of sex, gender, or sexual orientation in the educational
programs or activities it conducts.
More detail on SDSU’s Nondiscrimination Policy can be found in the SDSU General Catalog,
University Policies.
Student Conduct and Grievances
SDSU is committed to maintaining a safe and healthy living and learning environment for
students, faculty and staff. Sections 41301, Standards for Student Conduct, and Sections 4130241304 of the University Policies regarding student conduct should be reviewed.
If a student believes that a professor’s treatment is grossly unfair or that a professor’s behavior is
clearly unprofessional, the student may bring the complaint to the proper university authorities
and official reviewing bodies. See University policies on Student Grievances.
Statement on Plagiarism and Academic Dishonesty
Academic dishonesty includes cheating, plagiarism or other forms of academic dishonesty that
are intended to gain unfair academic advantage. See section 41301 of the University policies.
Plagiarism is an important element of this policy. Plagiarism is defined as ‘formal work publicly
misrepresented as original; it is any activity wherein one person knowingly, directly and for
lucre, status, recognition, or any public gain resorts to the published or unpublished work of
another in order to represent it as one’s own’. Any work, in whole or in part, taken from the
Internet or other computer-based source without referencing the source is considered plagiarism.
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