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 2010
3 Units
Day:
Time:
Location:
Schedule No.:
E-mail:
Office Location:
Monday
1600-1840
HH-134
22323
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 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]
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. [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 a health insurance topic will be required. The grading will be calculated as follows:
Exams
Assignment
Total
80%
20%
100%
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 make every effort to notify students in a timely manner.
COURSE CALENDAR
Week
1
2
3
4
5
6
7
8
Date
08/30
09/06
09/13
09/20
09/27
10/04
10/11
10/18
9
10
11
12
13
14
15
10/25
11/01
11/08
11/15
11/22
11/29
12/06
16
12/13
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
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
MD Reimbursements Systems Worldwide, Managed Care
Single Payer Systems with Global Budgeting
Health Insurance Selection Assignment Due.
International Financing Systems
Final Examination
Required Readings by Week and Topic (Subject to Revision)
Week
1
2
3
4
Topic
Introduction to Health
Insurance
Introduction to the Patient
Protection and Affordable Care
Act Health Reform Act of 2010
LABOR DAY
Actuarial Principles of Health
Insurance; Social Health
Insurance
Health Spending and Cost
Containment
Readings
”Financing Health Services,” Williams and Torrens,
Introduction to Health Services, 7th Edition, 2007,
Chapter 4.
No Class
Chapter 4 continued.
Micah Hartman, et al. Heath Spending Growth at a
Historic Low in 2008. Health Affairs, January 2010.
Henry J. Aaron, “Should Public Policy Seek to Control
the Growth of Health Care Spending?” Health Affairs,
January 2003, W3 28-36.
5
Social Health Insurance
Medicare Reimbursement
Principles and Benefits
Chapter 4 continued
6
Private Health Insurance
”Health Insurance,” Williams and Torrens, Introduction
to Health Services, Chapter 5.
7
Patient Protection and
Affordable Care Act Health
Reform Act of 2010
Midterm Exam;
Compilation of the Act (974 pages for reference)
Film, "Who Pays for Mom
and Dad?
Medicare Financing Principles
Medicare Inpatient Prospective
Payment System (IPPS)
Medicare Pay for Performance,
Medicare HMO payment
Long-Term Care Financing Principles
8
9
10
Medicare and You, 2010.
Five issue briefs from Kaiser Family Foundation
Chapter 4, pp. 97-101
P4P article TBD.
Randall S. Brown, et al. Do Health Maintenance
Organizations Work for Medicare? Health Care
Financing Review, 15(1):7-23. Fall 1993.
11
12
Medicaid Financing and
Benefits; Relation to Health
Reform
Medicare Physician
Reimbursement
Readings TBD
Hsiao, William C., et al., “Results and Impacts of the
Resource-Based Relative Value Scale.” Medical Care,
30(11):NS61-NS79. November 1992.
Levy, Jesse M. et al., “Understanding the Medicare Fee
Schedule and its Impact on Physicians Under the Final
Rule.” Medical Care, 30(11):NS80-NS94. November
1992.
13
Managed Care
MD Reimbursement Systems
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.
14
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. 3-16.
15
International Financing Systems Reinhardt, Uwe E., “Global Budgeting in German
Health Care: Insights for Americans.” Domestic
Affairs, pp. 159-194. Winter 1993/94.
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.
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.