Module 7 lecture, part 5

Question 1

CHIP is under what legislation?

Answer 1

Title XXI of SSA

Question 2

Aspects of CHIP

Answer 2

Federal block grants to states to expand Medicaid eligibility
First enroll in Medicaid if qualify
No federal income threshold, but typically for children (up to age 19) in families with incomes up to 200% of federal poverty level

Question 3

Purpose of CHIP

Answer 3

Cover children whose families’ income exceeded the Medicaid threshold levels

Question 4

Aspects of HC for the military by US DOD

Answer 4

HC for active duty and retirees, their dependents and survivors
Each branch of the military operates its own medical facilities; svcs are also obtained through civilian providers
TRICARE is the insurance arm

Question 5

Aspects of the Veterans Health Administration

Answer 5

The largest integrated health svc system in the US
Cost control through global budgets
Svcs organized through 23 geographically distributed Veterans Integrated Service Networks (VISNs)
CHAMPVA covers dependents of disabled veterans

Question 6

Aspects of the Indian Health Service

Answer 6

Federal program
Comprehensive care to federally recognized American Indian and Alaska Native Tribes and their descendants
IHS programs are the only source of HC for those living on reservations and in rural areas
IHS operates its own hospitals, health centers, and health stations

Question 7

What are the 2 facets of payment function?

Answer 7

Reimbursement
Disbursement

Question 8

Reimbursement definition

Answer 8

Determination of methods and amounts of reimbursement in advance of delivery

Question 9

Disbursement defintion

Answer 9

Actual payment after services have been rendered

Question 10

Charge definition

Answer 10

A price set by provider

Question 11

Rate definition

Answer 11

A price set by a 3rd party payer

Question 12

Fee schedule definition

Answer 12

An index of charges listing individual fees for each type of svc

Question 13

Who are 3rd party payers?

Answer 13

Insurance companies
MCOs
BlueCross BlueShield
Gov’t

Question 14

What are the types of reimbursement?

Answer 14

Fee for service
Bundled payments (package pricing)
Resource based relative value scale (RBRVS)
Managed care approaches
Cost-Plus reimbursement
Prospective reimbursement

Question 15

Aspects of fee for svc

Answer 15

The oldest method
Charges are set by the provider
Each svc billed separately
Later insurers adopted UCR (usual, customary and reasonable) charge
Main drawback is provider-induced demand

Question 16

Aspects of bundled payments (package pricing)

Answer 16

Reduces provider-induced demand because fees are inclusive of all bundled services
A number of related svcs in one prices
Evidence that prospectively set bundled fees reduced HC spending without compromising quality of care
Bundled Payments for Care Improvement (BPCI) initiative tested in Medicare

Question 17

Hx of resource-based value scale (RBRVS)

Answer 17

Developed by Medicare to reimburse physicians according to a relative value assigned to each physician service and was eventually adopted by other 3rd party payers

Question 18

Aspects of relative value units (RVUs)

Answer 18

Established by each CPT coded physician service
Reflect time, skill, and intensity
Separate RVUs assigned for overhead costs and malpractice insurance costs
Adjusted to reflect geographical cost variations

Question 19

What occurs each yr with RBRVS?

Answer 19

Medicare establishes a dollar conversion factor (CF)

Question 20

Reimbursement for a svc formula

Answer 20

Reimbursement for a service = RVU x CF

Question 21

Issue with RBRVS

Answer 21

A type of fee for service: not addressed the issue of volume-driven payment

Question 22

What are the 3 main approaches of MCOs?

Answer 22

Preferred provider
-Discounted fee for svc
Capitation
Salary combined with productivity-based bonuses in MCOs that employ their own physicians

Question 23

Aspects of capitation

Answer 23

Per member per month (PMPM) fee to cover all needed svcs
Monthly fee = PMPM rate x number of enrollees
Minimizes provider induced demand and promotes prudence

Question 24

What is the purpose of cost-plus reimbursement?

Answer 24

To reimburse HC institutions

Question 25

What is the cost-plus reimbursement?

Answer 25

Per diem rate of per patient day rate (PPD)

Question 26

What is cost-plus reimbursement based on?

Answer 26

Total operating cost + a portion of capital costs