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Humbio 120: US Health Policy > Section 5/Week 5 > Flashcards

Flashcards in Section 5/Week 5 Deck (32)
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1
Q

Managed Competition

A

a theory of health care reform.

a system of health care, either on a local, regional, state or national level in which patients choose between competing systems of managed care

2
Q

Managed Care is

A

a way of delivering care

3
Q

Alain Enthoven-Father of Managed Competition-proposed

A
  • employers should join together in Health Insurance Purchasing Cooperaatives (HIPC) to purchase health coverage
  • HIPC’s would in turn shop around among managed care plans to select the best options for their members
4
Q

What do consumers need to choose wisely

A
  • information about the quality of the care within the plan (HIPC responsible for making info available to consumers)
  • ability to compare prices for comparable levels of coverage (each plan must provide a basic level of coverage for all plans)
5
Q

What are some other characteristics required for for Managed Competition to work optimally

A
  • employer will only pay a fixed amount to purchase health coverage (employee must pay for any extras)
  • the tax codes would need to be changed (if employee chooses more expensive plan, the difference in price would be subject to income tax)
6
Q

Present day health insurance purchasing cooperatives

A

Health Exchanges!

7
Q

Clinton 1994

A

Failed health reform plan; based on the theory of managed competition

8
Q

Health Insurance Exchange under the Affordable Care Act

A
  • nonprofit, quasi-governmental organization that acts as a brokerage agency for a range of health insurance plans
  • organized on a state or regional basis
  • uninsured individuals go to the exchange to select a plan and to arrange government subsidy if eligible
9
Q

Health Insurance Cooperative

A
  • free-standing nonprofit health insurance company
  • formed by patients and members
  • need enough members to spread the risk of paying for health care
  • many contend it is no longer feasible to create patient cooperatives
10
Q

Although Clinton’s plan did not pass (fear of big govt), many private sector HIPC’s were able to be generated. What effect did these HIPCs have on health care

A
  • constrain the rise in premiums from year to year
  • establish a “standard benefits package” for all competing managed care plans to offer
  • publish comparative price and quality data in HEDIS for consumers to use in making health plan choices
11
Q

How long was managed care able to constrain costs for?

A

Until about 2001.

It stopped being able to contain costs because of growth in technology, an aging population, and increasing public expectations.

12
Q

What’s the new alternative to managed care

A

the consumer directed health plan (CDHP) with a health savings account (HSA)

13
Q

describe CDHPs and HSAs

A
  • patients are responsible for their medical care costs per year, with the hopes that they will use less care
  • HSA combined with a PPO with a high annual deductible
  • unused funds roll over to the next year
14
Q

Results of consumer-directed plan enrollment

A

-consumers cut back on the use of some beneficial services

15
Q

For-Profit ownership of managed care plans

A
  • 64% of patients enrolled in HMOs are in for-profit plans
  • Most PPOs are organized on a for-profit basis
  • PPOs have grown to have a larger market share than HMOs
16
Q

the for-profit corporation must balance the needs of the patient with

A

the needs of the shareholders

17
Q

What happened in the 1990s when the stock market had readily available capital

A

regional nonprofit plans were having trouble surviving, so there was a rapid consolidation into a relatively small number of national plans, most organized as for-profit corporations

18
Q

What is the medical loss ratio (MLR)

A

money paid by insurance companies for medical purposes

19
Q

What does the ACA mandate in terms of the MLR

A
  • for large group markets, MLR capped at 85%
  • for small group markets, MLR capped at 80%
  • companies that don’t meet MLR caps must refund the difference to their enrollees
20
Q

Control mechanisms used by managed care organizations

A
  • Gatekeeping (direct and indirect financial interest)
  • Bonus (direct and indirect)
  • Prior authorization
  • Emergency Care
21
Q

For-profit conversion was associated with

A

better subsequent financial health but had no relationship to the quality of care delivered or to mortality rates

22
Q

4 Basic Principles of Health Insurance Purchasing Cooperatives

A
  • Employees from a variety of companies band together to create a health insurance purchasing cooperative (HIPC)
  • HIPCs shop among other managed health care plans to select best options (professional staff evaluate the quality)
  • Managed care plans hoping to compete for business of HIPC would be required to offer basic benefit package, covering specified range of health care services (standardization)
  • HMOs and competing health plans would be free to offer coverage options beyond basic benefit package. Consumers would pay additional cost out of pocket.
23
Q

What are gatekeepers?

A

Patients must see primary care physician before they are permitted to consult a specialist, have a test, or be admitted to a hospital.

24
Q

Utilization Review

A
  • Staff of physicians and nurses that reviewed care provided
  • Had to obtain permission from utilization review department, failure to obtain this prior authorization led to managed care companies refusing to pay for service
25
Q

What are physician practice profiles

A
  • Gathered stats on how often each physician used expensive resources
  • Company penalized physicians whose profile exceeded what reviewers thought was appropriate
  • Managed care companies terminated contract of physicians
26
Q

What are holdbacks

A

Managed care companies held back a portion of the payment due to the physician (10-15%)

27
Q

What is a direct bonus

A

Amount of bonus determined by how well physician had kept costs down during the year (less ethical)

28
Q

What is an indirect bonus

A

Each physician receives a bonus in the form of a slice from the shared pool (more ethical)

-tied to the ability of medical groups as a whole to hold down costs

29
Q

Describe the Managed Care Backlash

A

Patients perceived that they were being denied appropriate care even though many of the utilization review practices were based on sound evidence. HMO’s gave up on many of their cost control strategies and health care costs began to rise again.

30
Q

What does the HEDIS Scale Measure? What does it not measure?

A

The HEDIS scale measures process; ie) how well a health plan follows well-established guidelines for the prevention or treatment of certain conditions (not health outcomes).

31
Q

How do for-profit and nonprofit plans compare on the quality-of-care measures included in the HEDIS scale?

A

Not-for-profits fare a little better on the HEDIS scale

32
Q

Do for-profit plans provide the same quality care to poor children on Medicaid as the do to children with private insurance?

A

Despite being enrolled in the same health plan, Medicaid children had lower HEDIS scale scores. Socioeconomic factors might be to blame for the differences in the scores.