Managed Care test 1 Flashcards
(101 cards)
1
Q
Where was the first example of an HMO?
A
TAcoma, Washington was a prepaid group practice for a set premium in 1910.
2
Q
What happened in Oklahoma that was part of the history of HMOs?
A
establishment of rural farmers’ cooperative health plan in Elk City in 1929.
3
Q
How did the AMA respond to prepaid groups?
A
takes a strong stance against them in favor of individual payments or indemnity-type insurance
4
Q
Tell me about the birth of the blues…
A
Came about during the depression. 1929 Blue Cross comes out of baylor and helps get teachers prepaid care. 1939 - blue shield comes out of physicians in pacific northwest who want to give employees coverage.
5
Q
How many workers had insurance in 1940?
A
10%
6
Q
What happened in 1942 which changed health insurance?
A
The stabilization act imposed wage and price controls but allowed benefits plan to aovid taxing.
7
Q
What Act gave the states the power to regulate insurance?
A
The McCarran-Ferguson Act.
8
Q
Can you explain the purpose of employee benefits and how they could have been included in the health care benefit package?
A
Know about stabilization act of 1942 and how it let benefits not be taxed.
9
Q
By 1955 how many workers had coverage?
A
70%
10
Q
What was JFK trying to do before his assassination?
A
trying to make national health plan for all Americans, especially elderly and poor.
11
Q
What happened in 1965 which was so important?
A
Creation of medicare and medicaid which was opposed by organization medicine.
12
Q
When were PPOs created?
A
in the 1970s, Samuel Jenkins startedd to negotiate discounts with hospitals and later on with physicians.
13
Q
What happened in 1973 and 1974 which affected managed care?
A
passage of federal HMO ACT and Employee Retirement Income Security Act (ERISA)
14
Q
Tell me about the 1973 Federal HMO Act.
A
Nixon proposed national health insurance. They noticed that medicare costs were out of control. Medicare paid by a cost plus basis (pay cost +2%).
Wanted to do two things?
- moving away from FFS
- provisio nof preventive care.
This act applied only to the commercial sector.
Gave start up funding to new HMOs, HMOs could elect to be federally qualified if meeting certain requirements, required to community rate premiums, employers >25 employees had to offer at least two types of HMOs to their employees.
15
Q
What are the types of HMOs?
A
closed panel, group, staff model, open panel, IPA/network model
16
Q
What were the drawbacks of the 1973 Federal HMO ACT.
A
HMOs could not compete because of the federal plan requirements, gov was slow in issuing regulations that implemented the act, employers delayed making HMOs available (dual-provision was done in 1995). After dual choice provision gone in 1995, states regulated HMOs.
17
Q
Tell me about the 1974 Employee Retirement Income Security ACt (ERISA).
A
This is where we get the origin of self-funding option for employers offering benefits plans (now over 50% of employers is self-funded).
ERISA exempts the benefits plan from most state laws and regulations such as state mandated benefits and state premium tax. Therefore, the state cannot mandate coverage requirements for self-funded plans.
18
Q
What is an insured, indemnified plan?
A
legal contract in which insurer accepts risk on behalf of insured in return for a premium
19
Q
When was CMS created and what was it called?
A
1977, health care financing administration.
20
Q
When did we start talking about quality?
A
national committee for quality assurance
21
Q
When do HMOs really start to appear?
A
early 1980s
22
Q
When did we start to see HMOs in Medicare?
A
in 1982 when we had the passage of the tax equity and fiscal responsibility act (TEFRA). Ronald Reagan was president. This is also the act where we get DRGs. Also we have the prospective payment system.
23
Q
What were TEFRA units?
A
the health care units which remained under cost plus after PPS was imposed on acute care inpatient. This would be a lot of outpatient stuff.
24
Q
What is COBRA?
A
consolidated omnibus budget reconciliation act of 1985.
25
WHAT did COBRA do?
EMTALA. This also had COBRA insurance. Created limitd health insurance coversion rights.
26
What is OBRA and what does it do?
omnibus budget reconciliation bill. Change medicare FFS payments to resource based relative value scale.
27
What is the resource based relative value scale and where did it come from?
OBRB.
28
What year did the rate of change of health care costs hit a bottom?
1996.
29
What remains of the true HMO?
utilization management, discharge planning. These are cost containment mechanisms.
30
Why did integrated health care delivery systems form?
as a response to managed care so that providers could have more negotiating power. Also, ability to take on risk for medical costs.
31
What are the multiple forms of integrated health caredelivry systems?
physician hospital organization, management service organizations, physician practice management company
32
What are "carve out" companies?
Those who specialize in managing a single aspect of care such as behavioral health care.
33
What did the balanced budget act of 1997 do?
Reduced payment levels to Medicare +Choice HMOs in most of the country below the rate of increase in medical costs and imposes additional administrative burdens.
34
What does HIPAA do?
1996. Increases access to health insurance, mandates some inpatient coverage for certain conditions, mandates mental health parity, does privacy and security.
35
Why do we have managed care backlash?
employers put a lot of employees in managed care plans, not as much choice, gatekeepers, overzealous utilization management, leads to patient's bill of rights.
36
What is a PPO?
preferred provider organization - like HMO but more freedom to go out of network because you don't have the gatekeeper.
37
What about the Medicare Modernization Act of 2003?
provided drug benefits to seniors, converted Medicare+Choice program into Medicare Advantage.
38
What do we mean when we talk about disease management?
focuses on the small percentage of members who have the highest costs
39
What two criteria do diease management conditions need?
1. condition is common
| 2. condition is likely to respond to a disease management program
40
What do disease management programs emphasize?
prevention of exacerbations and complications utilizing evidence-based practice guidelines, regularly updated, and patient empowerment strategies, to avoid or reduce admissions
41
What are some characteristics specific to disease management?
1. not physician-centric
2. lots of non-physician providers involved
3. ambulatory care setting
4. guidlines condition specific
5. behavioral aspects very important
6. much more telephone and internet contact
7. need for IT support
8. data must be collected from all sites of care annually
42
What is the use of the predictive model for disease management?
predictive modeling is a set of computerized tools used to risk stratify a population to identify opportunities for intervention.
43
Where do the predictive model get data sources?
medical claims, pharmacy, demogrphic data, HRA, lab data, transplant lists, external registries.
44
What is risk stratification?
risk stratification sorts patients with identified conditions into different risk levels. Allows for proper allocation of finite DM resources. They are stratified based on labs, manuals, predictive modeling.
45
What is outcome data and practice profiling used for in disease management?
a form of population baed retrospective review. They are looking for patterns of abnormal utilization or outcomes. May lead to action by increasing focus on problem areas.
46
What are some commonly used utilization metrics?
per member per month, per member per year, per thousand members, average length of stay
47
What is the equation which calculates institutional utilization?
A/(B/365)/(C/1000)
A = gross bed days per time unit
B = days per time unit
C = average plan membership for the time period - this is not total member months because it changes from month to month
48
Why does utilization vary widely?
physicians come to like certain tests and procedures, markets with more beds and physicians tend to use more.
49
Tell me about what kind sof payment model we are moving towards to make utilization necessary.
We were traditionally fee for service which providers like but led to overutilization. Capitation leads to under utilization. So we are moving towards a pay-for-performance.
50
Why are physician owned facilities and ancillary services a problem?
physician ownership of these things is associated with significantly higher use. Detection of this is not easy.
51
What are two ways in which we review physician owned facilities?
1. prospective review - focused on precertification is the most common approach
2. retrospective review - patterns of abuse are looked for.
52
What are the three basic types of utilization management?
1. basic UM
2. disease management
3. case management
53
What is the goal of utilization management?
see that each member receives the appropriate level of care at an appropriate cost by reducing unwarranted practice variation and managing utilization within clinical parameters in order to contain costs.
54
What is medically necessary and what is the problem with this definition?
This definition is not standard to everyone view medical necessity differently. Defined as items or services that may be justified as reasonable, necessary, and/or appropriate, based on evidence-baed clinical standards of care. This typically describes what is excluded from coverage as it is seen as not being medical necessary.
55
What things are not seen as medically necessary?
1. primarily for convenience
2. more costly than alternative service
3. assistance with acts of daily living
4. experimental or investigtional care
5. care not medically appropriate by generally accepted standards of medical practice
56
What does it mean to be evidence based?
medical guidelines support by peer-reviewed and published research by appropriate medical researchers. They are available through vendors or the AHRQ
57
What is basic utilization management?
Focuses on traditional inpatient and ambulatory facility care. Basic components are:
1. prevention
2. demand management
3. use of authorization system
4. use of protocols and guidelines
58
What are some components of a strong health plan prevention program?
1. member benefits for preventive services
2. service for members - health risk assessments, behavior change programs, membership discounts at fitness centers
3. contracts with providers
4. public policies
59
What is demand management and what is its goal?
goal is to lower the demand for costly services through the early provision of less costly services or self-care as appropriate.
60
What are some ways that they accomplish demand management?
1. nurse advice lines
2. self-care programs
3. shared decision making programs
4. health risk appraisals
5. personal health record.
61
Tell me about authorization systems that are used in basic UM.
This is about benefits determination. Not always a hard rule. Patient may need to have pre-certification for facility based authorization or pre-authorization for referral authorization by a PCP. This is about authorizing payment, not prohibiting a service.
Allows us to review the case for medical necessity and channel care to the most appropriate location.
62
What are some problems with authorization/
patient and PCP must get it for non emergency care. plan must define what services require or do not require authorization - this may not always be clear. plan must define who can authorize a service. HIPAA must be followed when these things are done.
63
What are the three categories of authorization?
1. prospective - issued before any service is rendered and applies to elective services
2. concurrent - generate at time of service, applies to urgent admissions. Done by UM nurses. They review all casess and see if they exceed LOS.
3. retrospective - takes place after review of claims for non-authorized services after the event, review of individual cases, review of patterns of utilization.
64
What happens to an authorization?
1. pended - for review
2. denial - no payment
3. subauthorization - one authorization allow creation of another
65
What does a medical director do?
communicates with physicians and daily review of utilization vs. exception review.
66
Who are some medical personnel who do utilization management?
1. medical director
2. UM nurses
3. hospitalist - full time hospital physician - short term impact on cost is positive but long term impact is negative
4. emergency department - requires special attention as this is the gateway to admission.
67
Tell me about discharge planning?
begins at time of admission and requires orchestration of services and benefits. It is with an interdiscplinary team.
68
What are the components of the discharge plan?
1. patient family understanding of illness
2. readiness of all to be involved in the plan
3. financial resources to help manage the disease
4. support resources to manage emotional response to diseae
5. education to patient
69
What is case management?
form of UM that is not primarily focused on benefits determination. Not limited to a defined set of chronic conditions. Begins at the patient's poit of entry.
70
What are some alternatives to acute care hospitalization?
1. outpatient ambulatory surgical centers - more fee for service which makes kind of expensive
2. subacute care - SNFs, for prolonged recovery cases, more cost effective than hospitals.
3. step down units - similar to SNFs but in the hospital. convenient for physicians and UM nurses.
4. hospice care
5. home health - common in MCOs
71
What is the most common element of all management care organizations?
network of contracted providers.
72
What is a service area?
specific geographic are in which it may sell its products and services. Indemnity type health plans can sell their product anywhere in the state in which they are licensed. HMOs must be to a specific provider area.
73
What is the professional network?
all providers except those working for facilities or in offices. Look at primary care, specialists, and hospital based providers (not necessarily those working for the hospital).
74
What does the ACA require in terms of access to PCPs?
requires direct access to PCPs and OB-gyns.
75
What are the five types of hospital based physician?
radiology, anesthesiology, pathology, emergency medicine, hospitalist
76
What is the problem with hospital based physicians?
patients do not have a choice in these as the hospital provides them. they often have monopology like negotiating power because they are associated with a certain hospital.
77
What is a hospitalist?
employed by medical group or hospital to take care of inpatients. impact on quality and outcomes is positive int he short run but negative in the mediumand long term (readmission)
78
What is the most common contracting situation between physicians and MCOs
they are trying to contract with individual physicians.
79
Why is it difficult to contract with medical groups rather than individual physicians?
medical groups are all or none (all physicians must agree). Small groups are similar to individual physicians but large groups are very complex. They have more negotiating leverage and are more likely to have greater capabilities such as EMR and diagnostics.
80
What is the most common form of HMO today as far as physician contracting?
independent practice associations. They contract with physicians and then with the health plan. Can align goals of the plan and the providers.
81
Tell me about independent practice associations.
Most common form of HMO today. contracts with physicians and then with HMO. all physicians in IPA must meet credentialing requirements ofplan. IPA may also carry out other functions such as CM, QM. This may be like a union though. The plan's ability to select and deselect individual physicians is limited and it may not be able to manage risk if it is fully capitated.
82
What are the advantages of negotiating in an integrated delivery system?
large, strong IDS has serious negotiating leverage. The health plan will have a diminished level of influence over the delivery system. Systems with large panel of employed physicians gain market power.
83
What are the disadvantages of negotiating in an integrated delivery system?
may not be able to manage risk if fully capitated.
84
What about faculty practice plans?
organized around teaching programs. May have single speciality or more specialties. The plan must take them all and hospital that faculty work for must force them all to contract or else they are out.
85
What about single specialty management company?
this company contracts with physicians. It is used to manage cost and quality for a single specialty, usually a high cost one. Good for capitation and risk-sharing.
86
What about rental networks and physician contracting situations
This is a rental PPO which is rented to different insurers to enlarge the network. Allows access to PPO management company's fee allowances.
87
What about retail clinics?
They are staffed by NPs, not physicians such as urgent care. Often in pharmacies and groceries stores.
88
How does the physician credentialing process work?
there is a standardized set of criteria in the national practitioner data bank and halth care integrity and protection data bank. Credentials are verified by the plan. Recredentialing occurs every 3 years.
89
Why do we care about physician network maintenance?
Network maintenance begins with orientation of new physicians and his staff. If the network doesn't provide this, physician may leave plan. The plans often have liaisons to the providers to help. The plan should monitor member service complaints to help the physician do better and remove them if they need to.
90
What are the types of hospital contracting situations?
1. community based single acute care hospitals
2. multi-hospital systems - must have them in network or your plan is at a serious disadvantage.
3. for profit national or regional chains
4. specialized hospitals
5. physician-owned isngle specialty
6. subacute or skilled nursing
7. hospice
8. ambulatory procedure facilities (either free standing or associated with hospital)
9. retail health clinics (treated as facilities)
10. urgent care
11. there are many, many more.
91
What is hospital tiering?
hospitals are categorized as tier 1 or tier 2 based on costs and outcomes. There is less cost sharing by the member for use of tier 1 hospitals.
92
What are some ancillary services?
laboratory, imaging, cardiac testing, other diagnostic testing - diagnostic
therapeutic - rehabilitation, PT, OT, speech,
93
What about credentialing facilities?
payers do not credential them, so they rely on state licensure. They also rely on accreditation agencies such as the joint commission.
94
Tell me about a patient centered medical home?
physician based
95
Tell me about accountable care organization?
facility based,
96
What are the non negotiable elements of all managed care contracts?
no balance billing, hold harmless, compliance with CM and UM programs, maintenance of clinical standards, licensure, malpractice insurance, maintenance and retention of records, nondiscrimination, compliance with HIPAA, acceptance of minimum # of patients from plan, compliance with certain administrative requirements
97
What are some negotiable elements of managed care contracts?
description of provider services under the contract, description of health plan's obligations to provider, payment terms are usually in appendix because they are more easily modified.
98
What does the National Practitioner Data Bank do?
malpractice payments, licensure actions, professional review actions, actions by DEA, exclusions by medicare or medicaid. Hospitals have to query HPDB at recredentialing of physicians and MCOs like to do it.
99
What is the health care integrity and protection data bank?
national health care fraud and abuse data collection program for reporting and disclosure of final adverse actions taken against health care providers, practitioners, or suppliers. Has civil judgments, criminal judgments, actions by agencies, exclusion of provders.
100
What does the ACA do to the national practitioner data bank and the health care integrity and protection data bank?
puts them together.
101
What are some of the rules when a contract ends?
abandonment, look at rules in book.
