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From Flashcardlet > Issues Powerpoints > Flashcards

Issues Powerpoints Flashcards

1
Q

What are the 3 methods used to determine premiums?

A
  • Experience rating
  • Community rating
  • Adjusted community rating
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2
Q

Group Insurance details.

A
  • Obtained through employer

- Anticipates that people will purchase insurance through sponsor

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3
Q

Self-insurance details.

A
  • Employers acts as its own insurer to employees

- Pay as injury incidents occur

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4
Q

Individual Private Health Insurance details.

A
  • Non-group plans

- Premiums based on individual’s health and demographics

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5
Q

Which insurances are classified as Managed Care Plans?

A

HMO’s and PPO’s.

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6
Q

What is the difference between HMO’s and PPO’s?

A

HMO’s have gatekeeping and capitating, while PPO’s do not.

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7
Q

High-deductible Health Plan (HDHP) details.

A
  • Higher deductibles in exchange for lower monthly premiums

- Deductible is higher before insurance company pays

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8
Q

Health Reimbursement Arrangement (HRA) details.

A
  • Employer makes an account and funds it for medical expenses
  • Medical expenses are are reimbursed and tax-free
  • Unused amounts roll over to next years
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9
Q

Health Savings Account (HSA) details.

A
  • An account available to individuals with high-deductible insurance plans
  • Set money aside in a special savings account
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10
Q

Medigap details.

A
  • Medicare supplmental insurance
  • Sold by private companies
  • Covers cost not paid for by original Medicare (co-payments, etc.)
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11
Q

What were the trends in employment-based health insurance over the recent years?

A

From 2005 to 2011, the percentage of private health insurance being employment based dropped 2.6%.

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12
Q

COBRA 1985 details.

A
  • Employment-based coverage can continue for 18 months after separation from job
  • Premium can’t exceed 102% of group premium
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13
Q

What are some compliance requirement for health plans?

A
  • 26 years old and under must be under parents’ plans
  • Coverage for pre-existing conditions
  • Coverage for preventative services without cost sharing
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14
Q

What is the Individual Mandate?

A

Everybody must have a minimum essential coverage or individuals will incur a penalty.

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15
Q

What are the two tests that health plans must meet for employers?

A
  • Minimum value test

- Affordability test

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16
Q

What is the minimum value test?

A

Plans must be equivalent to bronze plan through exchanges.

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17
Q

What is the affordability test?

A

Employee’s share of the premium for a single plan can’t be higher than 9.5% of household income.

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18
Q

What are the 6 Public Health Insurances?

A
  • Medicare
  • Medicaid
  • CHIP
  • Military Health Services
  • Veterans Health Administration
  • Indian Health Services
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19
Q

Medicare details.

A
  • Aka Title 18 of Social Security Act
  • Must be 65 y/o +
  • End-stage renal disease
  • Four part program
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20
Q

Medicare Part A details.

A
  • Hospital Insurance (HI)
  • Hospital Insurance Trust Fund is paid through payroll taxes
  • No premiums for individuals who have accumulated 40 credits (worked at least 10 years)
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21
Q

What are the Medicare Part A benefits?

A
  • Hospital care
  • Skilled nursing care
  • Home health care
  • Hospice
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22
Q

Medicare Part B details.

A
  • Supplementary Medical Insurance (SMI)
  • Voluntary program
  • Paid by general tax revenue and premiums based on income
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23
Q

What are the Medicare Part B benefits?

A
  • Doctor visits
  • Lab tests/X-rays
  • ER ambulance
  • Mental health
  • DME
  • Preventative meds
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24
Q

Medicare Part D details.

A
  • Prescription drug coverage
  • Voluntary
  • Requires monthly premium and deductible
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25
Q

Medicare Out-of-Pocket Costs details.

A
  • No limit on expenses in original Medicare program
  • Insured spends about 20% income on cost sharing
  • Half Medicare Advantage plans have cost sharing limits
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26
Q

How is Medicare Funded?

A
  • 2 trust funds held by U.S. Treasury
  • Hospital Insurance (HI) Trust Fund (Employers/Employees)
  • Supplementary Medical Insurance (SMI) Trust Fund (Congress)
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27
Q

What are the 3 issues of Medicare financing and spending?

A
  • Rising cost of delivering health care
  • An aging population
  • Shrinking workforce to support tax revenues
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28
Q

Medicaid details.

A
  • Title 19 of Social Security Act
  • For the poor
  • Financed by federal and state gov’t (matched)
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29
Q

Children’s Health Insurance Program (CHIP) details.

A
  • Title 21 of Social Security Act

- If not eligible for Medicaid, this program insures children

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30
Q

Military Health Services details.

A
  • Funded by U.S. Department of Defense (DOD)
  • TRICARE is the form of insurance for active duty
  • Paid for by gov’t, but uses private doctors/hospitals
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31
Q

Veterans Health Administration (VHA) details.

A
  • Owned/Run by federal gov’t
  • Health care providers are typically gov’t employees
  • Active duty and discharged (not dishonorably) are eligible
  • Due to high demand, there is a priority system
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32
Q

Indian Health Service (IHS) details.

A
  • Federal program
  • Care for Native Americans living on reservations/rural areas
  • Operates its own hospitals/health care centers
33
Q

What is Managed Care?

A

Delivering care to members through managing services and negotiating price with providers.

34
Q

What are the core features of Managed Care?

A
  • Integration of FIDP (Finance, insurance, delivery, and payment)
  • Control over utilization
35
Q

What are the 4 Quad Functions of Managed Care?

A
  • Finance
  • Insurance
  • Delivery
  • Payment
36
Q

What are the 4 stages of evolution leading up to Managed Care?

A
  • Baylor Plan (1929 [based on capitation])
  • Contract Practice
  • Prepaid group practice
  • Managed care
37
Q

What are the 5 domains that 2013 Healthcare Effectiveness Data and Information Set (HEDIS) have 80 measure for?

A
  • Care effectiveness
  • Access to and availability of certain services
  • Client experience of care
  • Utilization and resource use
  • Information on the health plan
38
Q

What are the two main factors for the growth of Managed Care?

A
  • Flaws in fee for service

- Weakened economic position of providers

39
Q

What were the flaws in Fee For Service?

A
  • Allowed insured to get service anywhere
  • Moral hazard and provider-induced demand was prevalent
  • Providers were billing insurer
40
Q

What were the Employer’s Responses to rise in premiums?

A
  • Initially, limited appeal for HMO’s

- Rise in premiums forced employers to abandon indemnity plans

41
Q

What were the Providers’ weakened economic position?

A
  • Excess capacity in hospitals

- Gave into momentum of managed care (participate or be left out)

42
Q

What are some efficiencies in Managed Care?

A
  • Elimination of insurance and payer intermediaries
  • Risk sharing with providers promotes prudent care
  • Monitors delivery of car
  • Delivers care cost-efficiently
43
Q

What are some inefficiencies with Managed Care?

A
  • Providers had to deal with numerous plans
  • Lab and other services not included
  • Lengthy appeals for denied auths
44
Q

Why is there a need for cost control in managed Care?

A
  • 10% of patients with chronic conditions account for 70% of health care spending
  • Hospital services cost about 50% of medical care
45
Q

What does Utilization Management require?

A
  • Evaluation of what services are needed
  • To be able to provide cheap services while maintaining quality
  • Review process of care
46
Q

What is Choice Restriction?

A

Based on patient’s choice to see in-network or out-of-network physicians.

47
Q

What are the 3 main strategies for Pharmaceutical Management?

A
  • Drug formularies
  • Tiered cost sharing
  • Pharmacy benefits management companies
48
Q

What are the 3 types of Utilization Review (UR)?

A
  • Prospective UR
  • Concurrent UR & discharge planning
  • Retrospective UR
49
Q

What is Prospective UR?

A
  • Deciding whether to refer or not
  • Precerts required
  • Second opinions
50
Q

What are the cost control methods for Concurrent URs?

A
  • Optimal drug therapy and management reduces length of stay

- Also reduces drug utilization and cost

51
Q

What is Retrospective UR?

A
  • Examine medical records
  • Analyze utilization
  • Billing accuracy
  • Review of practice patterns and feedback to physicians
52
Q

What is Practice Profiling?

A
  • Evaluate provider practice patterns
  • Feedback to change behavior
  • Goal is to improve quality and efficiency
53
Q

What are the 2 types of MCOs?

A
  • HMOs

- PPOs

54
Q

What are the 4 HMO Models?

A
  • Staff
  • Independent Practice Associations (IPA)
  • Network
  • Group
55
Q

How do you employ physicians on a Staff Model of an HMO?

A

By salary.

56
Q

What are the advantages to a staff model HMO?

A
  • Control over physicians

- Convenience of one-stop shopping

57
Q

What are the disadvantages to a staff model HMO?

A
  • Fixed salary expense can be high
  • Expanding is difficult
  • Limited choice of physicians
58
Q

What is the Group Model for HMOs?

A

A contract with a single multispecialty group practice with a paid capitation fee.

59
Q

What are the advantages to a group model HMO?

A
  • No salary or facility expenses

- Well known practice may lend prestige

60
Q

What is the disadvantage to a group model HMO?

A

If a contract is lost, service obligation struggles.

61
Q

What is the IPA Model for HMOs?

A

The physicians contract with providers.

62
Q

What are the advantages to an IPA model HMO?

A
  • Eliminates need for contract with various providers
  • Transfers financial risk to IPA
  • Choice of providers
63
Q

What are the disadvantages to an IPA model HMO?

A
  • If contract is lost, service obligation struggles
  • Utilization control is diluted
  • Surplus of specialists
64
Q

POS Plan details.

A
  • A cross between HMO and PPOs
  • Utilization controls and capitation remain
  • Open access option is available are point of service
65
Q

Where is Primary Care Case Management (PCCM) used?

A

In rural areas.

66
Q

What are the 3 main reasons for the Managed Care Backlash of the 1990s?

A
  • Employees faced barriers to free choice providers
  • Employees did not see lower out-of-pocket costs
  • Physicians reacted negatively to utilization management and lower reimbursement
67
Q

What are the 3 basic forms of Integration?

A
  • Management services organizations (MSOs)
  • Physician-hospital organizations (PHOs)
  • Provider-sponsored organizations (PSOs)
68
Q

What was Organizational Integration attempting to achieve?

A
  • Achieve economies
  • Diversify by offering new services
  • Gain market share
  • Gain leverage with health plans
69
Q

Describe the MSO form of integration.

A
  • Mainly used by small groups that cannot employ full-time managers
  • Supply management expertise, administrative tools, info tech to physician group practices
70
Q

Describe the PHO form of integration.

A
  • Alliance between hospital and physicians
  • PHO may contract with employers
  • Trend is for physicians to become hospital employees
71
Q

Why do physicians tend to become hospital employees?

A
  • Reimbursement cuts
  • High practice expenses
  • New demands (EHRs)
  • Younger physicians prefer employment
72
Q

Describe the PSO form of integration.

A
  • Risk bearing entity that competes with MCOs
  • Contract with employers and public insurers
  • Failed in large numbers due to lack of exp w/ insurance function
73
Q

What are the 3 Highly-Integrated Health Care Systems?

A
  • Integrated delivery systems (IDSs)
  • Accountable care organizations (ACOs)
  • Payer-provider integration
74
Q

Describe Integrated Delivery Systems (IDSs).

A
  • Coordinated continuum of services
  • Held clinically and fiscally accountable
  • Good quality, cost-saving hasn’t materialized
75
Q

Why did Managed Care promote the formation of IDSs?

A
  • Cost-effective
  • Preference to seek cost-efficient providers responsible for quality
  • Strengthened bargaining power
  • Protected autonomy
76
Q

Describe Accountable Care Organizations (ACOs).

A
  • Providers who take responsibility for delivering services to a defined population
  • Combine mechanisms of MCOs and IDSs
77
Q

Which type of hospital does not exist anymore?

A

Osteophathic hospitals.

78
Q

What are the 3 main issues on lack of clarity for ACOs?

A
  • Fate of smaller practices unclear due to hospital and large clinics joining hands
  • Unclear how safety-net providers will be included
  • Could dominate a market, reduce competition, and harm consumers through higher prices and lower quality
79
Q

Describe Payer-Provider Integration.

A
  • To gain control, insurance companies obtain large practices and health systems
  • Collaboration between MCOs and providers could be next major trend
  • Fear of encroachment from gov’t

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