4 - Risk considerations + Retro/Prospective Payment Systems Flashcards Preview

PUSHES > 4 - Risk considerations + Retro/Prospective Payment Systems > Flashcards

Flashcards in 4 - Risk considerations + Retro/Prospective Payment Systems Deck (11)
Loading flashcards...
1

Risk Spreading

Fundamental underpinning to health insurance (esp private)

POOL many people together to spread/share COSTS
generated by a small # of people

 

Sickest 5% account for 50% of healtchcare costs

Healthiest = 3% of costs

2

Adverse Selection

 

People with HIGH PERCEIVED NEED for health insurance are

More likely to want COMPREHENSIVE coverage than people with a lower percieved need for health coverage.

"Sicker-than-average" risk pool & higher costs

3

Favorable Risk Selection

CHERRY PICKING

Insurers include medical underwriting provisions.

Incentives to enroll "HEALTHIER-than average" risk pool

added benefits = gym etc

4

Moral Hazard

Individual behavior CHANGES when people are INSURED AGAINST LOSS

Consumer behavior leads to a HIGHER UTILIZATION of HEALTHCARE services
when the services are COVERED

5

RETROspective Payment Systems

Pay actual charges for services rendered by providers.

MORE RISK TO PAYERS
Less risk to Doctors

FEE-FOR-SERVICE

 

INCREASE IN: 
Admission / LOS / Intensity

6

FFS

Fee-For-Service Health Plan

Payment mechanism where seperate fee is paid for
EACH covered expense or service rendered

lab tests / exams / consult / office visit / fluids / supply 

MORE RISK to the PAYER

 

DISCOUNTED FFS = based on a percentage of the UCR charges
(usual / customary / reasonable charges)

7

PROSPECTIVE Payment Systems

PPS

PPS, negotiated payment RATES are determined BEFORE serves are rendered

Negotiated preset payment amounts

Contracted Rates set in ADVANCE for units of service

MORE RISK FOR THE PROVIDER

less risk for the payer

3 types:
Episode of Illness = DRGs / Per Diem / Capitation

8

Reimbursement by EPISODE OF ILLNESS

type of PROSPECTIVE Payment Systems (PPS)

 

Physician/hospital pays ONE SUM for ALL SERVICES delivered during one illness episode

Global Surgical Fees for physicians & diagnosis related groups (DRGs) for hospital

9

Diagnosis-Related Groups (DRG) SYSTEM

type of PROSPECTIVE Payment Systems (PPS)

Hospital inpatient admission/stays are classified 
not only according to clinical factors
but also RESOURCE CONSUMPTION

way to classify inpatients and measuring case mix

INCREASE
Admissions

Decrease
LOS / Service Intensity

10

PER DIEM payments

type of PROSPECTIVE Payment Systems (PPS)

Hospital/provider paid pre-established FLAT RATE for 
all services delivered to a patient during 
ONE DAY OF INPATIENT STAY
or per each day of OUTpatient service

INCREASE
ADMISSIONS + LOS

Decrease
Intensity of services

11

CAPITATION payments

type of PROSPECTIVE Payment Systems (PPS)

Negotiated, flat-rate payment to cover a person's medical care for a SPECIFIC PERIOD

PER MEMBER-PER MONTH

regardless of whether services are utilized

LIKE CAMPUS CARE

Decrease All
Admissions / LOS / Service Intensity