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Humbio 120: US Health Policy > Section 7/Week 7 > Flashcards

Flashcards in Section 7/Week 7 Deck (28)
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1
Q

What was the schedule of acceptable fees for physician services under Medicare originally based on?

A

UCR (usual, customary, reasonable) allowable fee.

Physicians were overcharging.

2
Q

What system replaced this first one?

A

The RBRV (resource based relative value) system based on how many resources each service require.

This system is preferred to keep costs down.

3
Q

What is the fundamental problem with the SGR?

A
  • Geographic scale is too big

- Not feasible

4
Q

What are potential solutions for reforming the Medicare physician payment system?

A

This is tough because Medicare Part A and B are separate.

  • smaller regions
  • accountable care organizations
5
Q

Why did Medicare start incentivizing patients to join HMOs?

A

To save $$$

6
Q

How did Medicare incentivize HMOs to treat Medicare patients

A
  • Federal government would pay HMOs that were enrolling Medicare beneficiaries on cost reimbursement
  • HMOs expected to save 70%
7
Q

Why did Medicare HMOs experience favorable selection?

A

They enrolled disproportionatley healthy people and made significant profits.

-Law said that profits had to be given back to the patient in benefit or reduction. Solution was to provide more coverage.

8
Q

What impact did HMO increasing usage have on Medicare’s costs?

A

Drove costs up again, as more care was being provided unnecessarily.

9
Q

What is Medicare+Choice?

A

Product of Balanced Budget Act of 1997, allowed for a wider range of managed care options.

10
Q

What was the unintended consequence of decreasing hospital payments under the Balanced Budget Act of 1997?

A

Hospitals were facing hardships, often times having to close.

Especially true for teaching hospitals and urban hospitals.

11
Q

What was the unintended consequence of risk-adjusted capitation premiums to Managed Care Plans-meaning adjusting the premium annually based on the previous health status of the beneficiary?

A

Decrease in HMO enrollment because of increased premiums and decreased availability.

12
Q

What was the Medicare Modernization Act of 2003?

A
  • attempt to bring HMOs back after mass exodus
  • increased capitation rates
  • created Part D
  • ended up paying 114% of the costs of Traditional Medicare
13
Q

Medicare HMOs

A

With rising health care costs in 1970s and 1980s, the federal government allowed beneficiaries to enroll in certain approved HMOs

14
Q

Balanced Budget Act of 1997

A

An attempt by Congress + President Clinton to change the financing and organization of many federal policies, including Medicare reform

15
Q

Medical Savings Accounts

A

A high deductible plan in which Medicare gives individuals in Medicare the difference between the average cost to be enrolled in an HMO and the patient’s high deductible. Excess funds are put into a savings account and can be used for health care or other income taxed related spending.

16
Q

Medicare + Choice

A

An attempt by Congress to allow Medicare enrollees market-based choices for their care. They had a wide range of choices from traditional Medicare to PPO, HMOs, POS, MSAs and other combinations

17
Q

What populations are covered under Medicaid?

A

Rather than being universally available to all poor people, it covers only certain subgroups

18
Q

How is Medicaid payment structured?

A

Rather than combining a service plan and an insurance plan, it originally was strictly an insurance plan.

19
Q

How is Medicaid administrated

A

By the states under broad federal guidelines.

20
Q

Whos eligible for Medicaid?

A
  • Members of low-income families with children
  • Elderly people who meet income requirements
  • Disabled people
21
Q

What services are provided by Medicaid

A

There is a basic level of services a state’s program must provide in order to qualify for financing, but if a state so desires they can add any additional services and receive federal matching funds.

22
Q

Many states have constitutions that ban deficit spending. Why is this of particular concern in regards to Medicaid during recessions?

A

More people are unemployed and go on Medicaid
Revenue for Medicaid is cut because less people are employed, paying taxes
So, states must cut spending in Medicaid or other public services at a time when these services are needed most.

23
Q

What was the original language of the Medicaid amendment in 1965

A
  • Provided federal matching funding to states to cover medical costs for the “poor” who met certain tests
  • Sate enrollment was optional, encouraged by federal matching funds
  • Based largely on the ‘insurance’ model
24
Q

How has Medicaid been impacted by the recession

A

-Rose by nearly $6million

25
Q

Why are Medicaid patients abusing emergency rooms?

A

Because there is a poor availability of doctors is largely responsible for the following relationship.

26
Q

Oregon Health Plan

A
  • Another way of confronting Medicaid costs
  • Required a special waiver from the federal goverment
  • Led to the explicit rationing of medical care for Oregon’s poor
27
Q

What are changes to Medicaid under the ACA

A
  • All people with income below 138% of the poverty line are automatically eligible for Medicaid, regardless of family status
  • Newly enrolled Medicaid beneficiaries will have matched funds from the government at 100% of the cost, gradually reducing to 90%
  • State participation is optional
28
Q

How is the physician payment system under Medicaid changed under the ACA

A

-Beginning in 2013, any primary care physician treating a Medicaid patient will be paid at the same rate as the Medicare rate