APA Style Critical Reflections Papers, Health & Medical Homework Help (2-3 Pages)


1. Introduction
(25%) Arrange for a brief summary of the meaning (not a description) of
each Chapter and articles you read, in your own words.
2. Your Critique
What is your feedback
to the content of the articles?
What did you learn
about the components of a health services delivery system?
What did you learn
about the systems framework?
How you can apply your new knowledges to primary
characteristics of the US health care system?
What does the Health Care Administrator need to know about
health promotion and disease prevention?
Did these Chapter and
articles change your thoughts about public health and significance for managers
and policymakers? If so, how? If not, what remained the same?
3. Conclusion
Fleetingly recapitulate
your thoughts & deduction to your assessment of the articles and Chapter
you read.  How did these articles and
Chapters influence your thoughts on US Healthcare system  and
public health?
Evaluation will be based on how clearly you respond to the
above, in particular:
a) The clarity with which you critique the articles;
b) The depth, scope, and organization of your paper; and,
c) Your conclusions, including a description of the impact
of these articles and Chapters on any Health Care Setting.


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IBM Global Business Services
IBM Institute for Business Value
Healthcare 2015 and
U.S. health plans
New roles, new competencies
IBM Institute for Business Value
IBM Global Business Services, through the IBM Institute for Business Value,
develops fact-based strategic insights for senior executives around critical public
and private sector issues. This executive brief is based on an in-depth study by
the Institute’s research team. It is part of an ongoing commitment by IBM Global
Business Services to provide analysis and viewpoints that help companies realize
business value. You may contact the authors or send an e-mail to iibv@us.ibm.com
for more information.
Healthcare 2015 and U.S. health plans
New roles, new competencies
By Jim Adams, Barbara A. Archbold, Edgar L. Mounib and David New
The U.S. healthcare system is on an unsustainable path that will force its
transformation. As a result, we are witnessing changes to the purchasing,
consumption and delivery of healthcare that will redefine the way health plans
compete and operate. With this in mind, U.S. health plans should reassess
what their future role will be, what competencies are needed to support this
role, and how they will create value for customers and outperform competitors.
They must also help shape and lead this healthcare transformation, or risk
being marginalized.
The environment in which U.S. health plans
operate is fundamentally changing as the
healthcare system struggles to address everincreasing cost, quality and access pressures.
U.S. healthcare expenditures per capita are
2.3 times higher than that of other developed
countries and are projected to increase 83
percent over the next ten years.
Despite this spending, there are quality
concerns. For example, medical errors cause
between 48,000 and 98,000 patient deaths
each year and medication errors cost over
US$3.5 billion annually. There are also significant access issues as 47.0 million Americans
are uninsured and an additional 15.6 million
are underinsured for catastrophic healthcare
expenses. Although cost, quality and access
issues are not new in the U.S., we believe
today’s healthcare environment has fundamentally changed, and, more importantly, is

Healthcare 2015 and U.S. health plans
As documented in “Healthcare 2015: Winwin or lose-lose?,” five factors – globalization,
consumerism, aging and overweight populations, diseases that are more expensive to
treat, and new medical technologies and
treatments – are exacerbating cost, quality
and access pressures. Change will not
come easily, though, given the inhibitors to
transformation – funding constraints, societal
expectations and norms, a lack of aligned
incentives, the inability to balance short-term
and long-term perspectives, and the inability
to access and share information.In this prior
paper, we also identified three prescriptions
for healthcare systems – transforming value,
transforming consumer responsibility and
transforming care delivery – in order to help
countries remain competitive in a global
The challenge today is whether stakeholders
are willing and able to transform the healthcare
system. We believe that the status quo is
not a viable alternative and major changes
will occur. Given the wide variety of potential
changes, we will state the following assumptions to limit the range of possibilities.
We believe that the U.S. healthcare system
will not achieve a comprehensive “win-win”
transformation by 2015 because of political
gridlock and the inability of key stakeholders
to work collaboratively to reach solutions for
the “greater good.” Instead, we expect to see
a piecemeal and incremental improvement
approach implemented as a series of “point
Additional assumptions for the U.S. healthcare
system through 2015 include the following:
• Universal coverage will be enacted, either
nationally or on a state-level basis in a significant number of states, but alone, it will not
solve the problem. Even if enacted nationally,
it will not be administered and managed by
the federal government. And because of the
“job lock” challenge created by tying health
insurance to employment, most universal
coverage solutions will focus on individual
coverage rather than requiring employersponsored coverage.
• Health and financial responsibility will
continue to be transferred to individuals.
• Healthcare delivery models and capabilities
will continue to proliferate at increasing rates.
However, no major efforts will be taken to
control the supply side of healthcare.

• Health plans will not be immune to these
healthcare system changes. Caps on health
plan administrative costs and profits could
be enacted either in some states or on a
national basis.
Combining potential “quick-fix solutions” such
as a single payer system with other factors
such as the lack of trust and confidence in
health plans have led many pundits to predict
a bleak future for U.S. health plans. But that
is not a predestined future. Health plans can
– and should – help lead the transformation
to a more patient-centric, value-based,
accountable, affordable and sustainable U.S.
healthcare system. This will also require health
plans to transform themselves.
A typical successful U.S. health plan in 2015
could look quite different from today’s health
plan – with major changes in key roles
and with significantly fewer employees in
some roles and more in other roles, some
commodity functions outsourced, some
functions performed collaboratively with or by
business partners, and greatly improved and
enhanced business processes and IT-related
capabilities with a much greater focus on
maintaining or improving its members’ health.
The purpose of this study is to provide recommendations for health plans regarding what
they need to do to thrive in the new order.
In the next sections, we examine how key
external factors will evolve and affect health
plans. We then conclude with a description
of key roles that health plans will assume
and competencies needed in order to meet
the evolving needs of the marketplace
and to succeed in a much different future
Healthcare 2015 and U.S. health plans
New roles, new competencies
On the surface, the
staggering growth
expected in healthcare
expenditures suggests
opportunities for U.S.
health plans, but it
also brings complexity
and challenge.
Emerging challenges to
U.S. health plans
Health plans are experiencing a period of
financial prosperity. This reflects the industry’s
shift in focus from enrollment growth to overall
earnings growth, as well as health plans’
ability to effectively price ahead of actual
claims in recent years. The industry was also
boosted by expansion of new U.S. markets,
such as Medicare with the passage of the
Medicare Prescription Drug, Improvement and
Modernization Act (MMA) of 2003. Investors
have welcomed and rewarded these changes
(see Figure 1).
Looking forward, U.S. healthcare expenditures
are forecasted to increase from US$2.26 trillion
(US$7,498 per capita) in 2007, to US$4.14 trillion
in 2016 (US$12,782 per capita, 6.9 percent
annual growth). While this will seemingly
offer health plans new opportunities, it will also
pose new challenges.
The growth in healthcare spending, combined
with drivers for healthcare transformation,
will have three key impacts on health plans
(see Figure 2). In this section, we explore the
challenges resulting from these changes in
how healthcare will be purchased, consumed
and delivered.
Investors have rewarded health plans for their recent earnings growth.
Cumulative growth (%)
Healthcare payer index
S&P 500 index
1997 1998 1999
Note: “Healthcare payer index” refers to Morgan Stanley’s “Healthcare Payors Index” (^HMO).
Source: Yahoo! Finance, January 1997 through July 2007.

Healthcare 2015 and U.S. health plans
Health plans will encounter key challenges in the
evolving healthcare system.
Healthcare 2015 drivers
Impact on health plans
Purchasers shifting
from employer-based to
and individual coverage
Aging and overweight
Consumers bearing
increasing responsibility
and accountability
Diseases that are
expensive to treat
New treatments
and technologies
Providers facing new
healthcare requirements,
delivery models,
capabilities and
reimbursement models
Source: IBM Global Business Services and IBM Institute for
Business Value.
Purchasers – Shifting from employer-based
to government-based and individual coverage
Since its inception during World War II,
employer-sponsored health coverage has
been a vital component of the U.S. healthcare
system. Sixty-one percent of the nonelderly
population receives its health insurance
coverage from employers.
However, employers have struggled to provide
coverage as premiums have increased at
multiples of general inflation and workers’
earnings (see Figure 3). Looking forward,
premiums are forecasted to increase even
further. Employer-sponsored health benefits
for family coverage will increase from US$8,167
(18 percent of median household income) in
2005, to US$17,362 (30 percent) in 2015 (7.8
percent annual growth). Single coverage will
increase from US$3,413 (8 percent of median
household income) in 2005, to US$7,368 (13
percent) in 2015 (8.0 percent annual growth).
Employers have been exploring various
options in response to rising premiums.
• Controlling costs among active employees.
In the 1990s, employers turned to restrictive
managed care models – a move ultimately
rejected by patients and providers. Employers
have since turned to preferred provider
organizations (PPOs) as a more flexible, but
also more costly, alternative. In 2006, PPOs
accounted for 60 percent of private insurance
enrollees, an increase from 41 percent in
Year-on-year growth (%)
Employers have struggled to keep up with increasing healthcare costs.
Health insurance premiums
Overall inflation
Workers’ earnings
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Source: The Kaiser Family Foundation and Health Research and Educational Trust. “Employer health benefits 2006 annual survey.” 2006.

IBM Global Business Services
Employers have been
exploring various
options in response to
rising premiums.
Employers are increasingly sharing healthcare costs with their employees in the
forms of higher deductibles for hospital/
physician services and co-payments for
drugs. Employees are also paying higher
premiums, as their monthly contributions
have increased from US$129 for family
coverage in 1999, to US$248 in 2006 (9.8
percent annual growth); single coverage
increased from US$27 to US$52 (9.8 percent
annual growth).
• Restricting retiree benefits. Employers’
commitment to retirees has also weakened,
for example, as coverage among large
firms (200 or more workers) decreased
from 66 percent in 1988 to 35 percent in
2006. Reasons include rising healthcare
costs, increasing life expectancy and
changes to the Governmental Accounting
Standards Board (GASB)/Federal
Accounting Standards Advisory Board
(FASAB) requirements.
Benefits are increasingly targeting the
management of prevalent chronic conditions, as well as promoting healthier
lifestyles, such as: offering incentives
for smoking cessation, physical activity
and completing health risk assessments; providing on-site fitness facilities;
providing healthy lifestyles counseling;
and eliminating deductibles or co-pays
for preventive care. Additionally, some
employers are penalizing employees for
unhealthy behaviors by imposing financial
penalties for poor physiologic measures,
such as high cholesterol or blood pressure
readings. However, the current challenge
is to determine what is really needed to
change consumer attitudes and behaviors.
Among employers who offer retiree health
benefits, the qualifications for coverage
are becoming more stringent. For example,
employers are increasingly tightening eligibility requirements, such as rewarding longer
service employees. Many are also incorporating caps or ceilings on their future retiree
health obligations. This can limit their liability
by requiring retirees to assume a greater
share of costs if and when spending on a
particular retiree healthcare plan exceeds its
cap. Among the employers polled in a 2005
survey, 49 percent indicated they had a cap
on their largest retiree health plan. For those
with these plans, 59 percent had already
hit the cap, 8 percent will hit it in the next
year, 19 percent will reach it in the next three
years and 14 percent will not hit it in the
near future.
Employers are increasingly eliminating
coverage altogether. The proportion of
employers offering coverage to working age
adults has declined from 69 percent in 2000
to 61 percent in 2006 and is projected to
drop below 50 percent by 2015, impacting
both health plans and their brokers. This
decline will particularly affect employees
of employers that have a smaller number
of employees, have a higher proportion of
lower-wage employees and a lower propor17
tion of union workers.

Healthcare 2015 and U.S. health plans
• Shifting from full to self-insurance. Between
1999 and 2006, self-insurance rates
increased from 44 to 55 percent among
all employers, and from 62 to 89 percent
among employers at firms with 5,000 or
more employees. This approach is attractive for various reasons. Employers are
able to spread risk across large pools of
enrollees and often purchase stop-loss
insurance to limit their exposure. Moreover,
per ERISA (the Employee Retirement Act of
1974), self-funded plans are exempt from
state regulations covering things such as
reserve requirements and premium taxes.
As employer-sponsored coverage erodes,
Americans will be forced to seek out other
coverage options or forego coverage.
Some will turn to the individual markets and
purchase their own health plans. The number
of U.S. subscribers to individual coverage has
risen from 16.1 million in 2000 to 17.8 million
in 2005 and is expected to increase to 20
million in 2010.
The combination of
the push for universal
coverage, the erosion
of employer-sponsored
insurance and the aging
population is expected
to drive this continued
shift to individual and
Federal and state governments will provide
coverage relief to other Americans. Medicaid
enrollment is projected to increase 14 percent
from 62.2 million in 2007 to 70.8 million in
2015. However, benefit spending will rise
90 percent from US$172.2 billion in 2007 to
US$326.2 billion in 2015 (8.3 percent annual
growth). This increased spending will be
driven by the elderly and disabled enrollees
who account for 25 percent of membership
but 70 percent of spending. These mounting
demands will particularly strain states’ ability to
manage and fund the Medicaid program.
Medicare is being tested by the aging of
the population. As in the case of Medicaid,
growth in Medicare expenditures will accelerate faster than enrollment. That is, Medicare
enrollment is expected to increase 22 percent
from 43.8 million in 2007 to 53.6 million in 2015,
while spending will increase 82 percent from
US$437.9 billion in 2007 to US$798.5 billion in
2015 (7.8 percent annual growth). Moreover,

IBM Global Business Services
total Medicare expenditures are expected to
increase at a faster pace than either workers’
earnings or the economy overall. And, the
funding for Hospital Insurance, or Medicare
Part A, is projected to be exhausted in 2019.
In summary, the combination of the push for
universal coverage, the erosion of employerbased insurance and the aging population
is expected to drive this continued shift to
individual and government-based coverage.
Consumers – Bearing increasing
responsibility and accountability
Consumers are assuming greater responsibility for managing and paying for their
healthcare services, as well as their personal
health management. If they are to successfully
do this, they will need to make more sound
health and wellness choices, realize greater
value from the healthcare system, and make
better financial plans for future healthcare
needs (see Figure 4).
Consumers must make wiser health and financial
decisions as patients and purchasers.
Better health
care delivery
planning for
“Health infomediaries”
Health coach
Value coach
Wealth coach
Better access to information
Source: IBM Global Business Services and IBM Institute for
Business Value.
As they assume greater
responsibility for
managing and paying
for their healthcare,
consumers will be
rewarded for good health
and lifestyle choices.
Better health through better choices
Today, many consumers largely disregard
personal lifestyle. Lifestyle factors such
as diet, smoking, exercise, alcohol, sleep,
weight and stress have the largest impact
on personal health status. However, the
relative widespread neglect of them has
resulted in the increased incidence in illnesses
and conditions that dramatically reduce
the consumer’s quality of life. One study, for
example, estimated that half of all deaths
in the U.S. could be attributed to largely
preventable behaviors and exposures.
Looking forward, we believe lifestyle choices
will be more explicit and poor choices
will come with short-term consequences.
Healthier consumers will need less healthcare
and, as a result, will pay less in total healthrelated expenditures and treatments. Healthy
living education and behavior change
programs will be prevalent.
Personalized high-value care delivery
Consumers will need to better realize value
from the healthcare system as they increasingly assume greater responsibility for their
healthcare. This is demonstrated by the
increasing coverage by HSA/high-deductible
health plans. According to America’s Health
Insurance Plans (AHIP), 4.5 million Americans
are covered by HSA/high-deductible health
plans in 2007, an increase of 1.3 million over
the previous year.
As consumers bear the financial burden of
managing their healthcare, they will need to
effectively navigate through the healthcare
system to optimize their patient-centered,
value-based, episodic and longitudinal
care experiences. This includes selecting

Healthcare 2015 and U.S. health plans
the appropriate health plan, providers, and
diagnostic and therapeutic treatments for the
consumer’s unique situation and also appropriately coordinating care and communicating
across provider settings.
Better financial planning for healthcare
The need for financial planning for consumerborne total healthcare expenditures is a critical
need as healthcare costs keep rising and a
larger portion of the financial burden continues
to be shifted to the consumer. For example,
a 65-year-old couple that retired in 2006 and
lived to an average U.S. life expectancy (82
years for men and 85 years for women) would
require an additional US$295,000 in savings to
supplement Medicare. If this couple lived until
95 years, they would need US$550,000 (see
Figure 5). A couple retiring in 2016 at 65 years
of age would need US$560,000 if they lived
an average lifespan. They would need US$1.05
million if they lived to 95 years. Many people
are poorly prepared for these expenses, with
over 40 percent of people over 55 having
US$50,000 or less saved. Not surprisingly,
half of all bankruptcies are in part due to
medical expenses.
Projected savings needed per individual for sufficient Medicare supplementa …
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